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PAEDIATRICS > GASTROENTEROLOGY PAEDS > Flashcards

GASTROENTEROLOGY PAEDS Flashcards

1
Q

Medical differentials for abdo pain in children

A 
Constipation 
UTI, pyelonephritis, hydonephrosis, renal calculus 
DKA 
Coeliac 
IBD, IBS
Mesenteric adenitis 
Henoch-schonlein purpura 
Infantile colic 
Gynae in pubertal females 
Sickle cell 
Etc.
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2
Q

Surgical differentials for abdominal pain

A 
Acute appendicitis 
Intussusception 
Bowel obstruction 
Testicular torsion 
Inflamed meckles diverticulum
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3
Q

RED FLAGS for abdominal pain

A 
Persistent or bilious vomiting 
Severe chronic diarrhoea 
Fever
Rectal bleeding 
Weight loss/faltering growth 
Dysphagia 
Nighttime pain 
Abdominal tenderness
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4
Q

What is abdominal migraine?

A

Central abdo pain lasting more than 1 hour
Normal examination
May be Associated with: N&V, Anorexia, Pallor, Headache, Photophobia, Aura

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5
Q

Treating abdominal migraine

A

Similar to typical migraine
Treating attack: Low stimulus environment, ibuprofen, SUMATRIPTAN, PARACETAMOL
Preventative (started by specialist) PIZOTIFEN (serotonin agonist)
Other preventative (less commonly used): PROPRANOLOL (non-selective beta-blocker), FLUNARAZINE (ca channel blocker), CYPROHEPTADINE (antihistamine)

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6
Q

Causes of constipation in paeds

A

Idiopathic/functional

Secondary causes: Hirschsprung’s disease, cystic fibrosis, hypothyroidism, coeliac

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7
Q

What is Desensitisation of the rectum ?

A

Poor bowel habits + ignoring the sensation of a full rectum —> loss of sensation —> less frequent opening of bowels —> faecal impaction —> further desensitisation of rectum from stretching

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8
Q

Constipation red flags

A

Not passing meconium within 48hrs of birth (Hirschsprung’s, CF)
Neurological signs or symptoms (Cerebral palsy, spinal cord lesion)
Vomiting (obstruction, Hirschsprung’s)
Ribbon stool (Anal stenosis)
Abnormal anus (anal stenosis, IBD, Sexual abuse)
Abnormal lower back or buttocks (Spina bifida, spinal cord lesion etc.)
Acute severe abdo pain and bloating (obstruction or intussusception)

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9
Q

Complications of constipation

A 
Pain 
Reduced sensation 
Anal fissures 
Haemorrhoids 
Overflow and soiling 
Psychosocial morbidity
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10
Q

Management of constipation

A
  • Correct any reversible contributing factors (Diet, hydration)
  • Start laxatives (MOVICOL first line)
  • Faecal impaction may require disimpaction regime + high dose laxatives
  • Encourage and praise visiting toilet - scheduling visits, bowel diary, star charts

Laxatives continued long term and slowly weaned off

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11
Q

What is Hirschsprung’s disease?

A

Congenital condition - nerve cells of the myenteric plexus are absent in the distal bowel and rectum
Forms part of the enteric nervous system - the brain of the gut and responsible for stimulating peristalsis of the large bowel.
ABSENCE OF PARASYMPATHETIC GANGLION CELLS - severity varies as could be small amount of colon or the full length

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12
Q

Hirschsprung’s disease: Presentation

A

Can present as acute intestinal obstruction shortly after birth, or more gradually developing symptoms such as:

  • Delay in passing meconium (>24hrs)
  • chronic constipation from birth
  • abdo pain and distension
  • vomiting
  • poor weight gain and failure to thrive
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13
Q

Hirschsprung-associated enterocolitis (HAEC)

A

Inflammation and obstruction of instestimes in neonates with Hirschsprung’s
Typically presents in first 2-4 weeks of life
Fever, abdo distension, diarrhoea, features of sepsis
LIFE THREATENING - can lead to toxic mega colon and perforation of the bowel

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14
Q

Management of Hirschsprung-associated enterocolitis

A

Urgent antibiotics, fluid resuscitation and decompression of the bowel

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15
Q

Management of Hirschsprung’s disease

A

ABDO X-RAY - identify intestinal obstruction / features of HAEC
RECTAL BIOPSY - confirm diagnosis (absence of ganglion)
FLUID RESUSCITATION and MANAGEMENT OF OBSTRUCTION
Definitive management: SURGICAL REMOVAL OF AGANGLIONIC SECTION OF THE BOWEL

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16
Q

Signs of problematic gastro-oesophageal reflux

A 
Chronic cough 
Hoarse voice 
Distress/crying or unsettled after feeding 
Reluctance to feed
Pneumonia 
Poor weight gain
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17
Q

GOR - Red Flags

A

Not keeping down any feed (Pyloric stenosis, intestinal obstruction)
Projectile or forceful vomiting (Pyloric stenosis, intestinal obstruction)
Bile stained vomit (Intestinal obstruction)
Reduced consciousness, bulging fontanelle, neurological signs (Meningitis, RICP)
Resp symptoms (Aspiration, infection)
Blood in stools (gastroenteritis, cows milk protein allergy)
Signs of infection
Rash, angiooedema, and other signs of allergy (Cow’s milk protein allergy)
Apnoeas

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18
Q

GOR: Management

A

Small frequent meals
Burping regularly to help milk settle
Not over-feeding
Keeping baby upright after feeding

Gaviscon mixed with feeds
Thickened milk/formula (Anti-reflux)
Ranitidine
Omeprazole where ranitidine is inadequate

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19
Q

Where is the pyloric sphincter

A

Ring of smooth muscle that forms the canal between the stomach and the duodenum

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20
Q

What is pyloric stenosis?

A

Hypertrophy (therefore narrowing) of the pylorus
Prevents food travelling from the stomach to the duodenum as normal
After feeding there is powerful peristalsis in the stomach - becomes to powerful it ejects the food into the oesophageal and out the mouth - PROJECTILE VOMITING

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21
Q

Pyloric stenosis characteristics

A

First few weeks of life
Baby - hungry, thin, pale, failing to thrive
Projectile vomiting
Peristalsis can sometimes be seen on examination
Upper abdo: firm round mass (feels like a large olive)
Blood gas: hypochloric METABOLIC ALKALOSIS (baby vomiting hyperchloric acid)

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22
Q

Pyloric stenosis: diagnosis

A

ABDO ULTRASOUND

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23
Q

Pyloric stenosis: treatment

A

Laparoscopic pyloromyotomy

- incision made into muscle to widen canal

24
Q

Define acute gastritis

A

Inflammation of stomach

Nausea & Vomiting

25
Q

Define Enteritis

A

Inflammation of intestines

Diarrhoea

26
Q

Define Gastroenteritis

A

Inflammation all the way from the stomach to the intestines

Nausea, vomiting, and diarrhoea

27
Q

Key conditions to consider if child presents with LOOSE STOOLS

A 
INFECTION (gastroenteritis) 
IBD
LACTOSE INTOLERANCE
COELIAC DISEASE 
CYSTIC FIBROSIS 
IBS 
MEDICATIONS
28
Q

Most common causative agents of gastroenteritis

A 
VIRAL most common 
- Rotavirus 
- Norovirus 
- Less common: adenovirus 
Others: Bacterial
- E. Coli, campylobacter Jejuni, shigella, salmonella, bacillus cereus, staphylococcus aureus toxin, giardiasis
29
Q

Why should antibiotics be avoided in E.Coli gastroenteritis?

A

Increases the risk of HAEMOLYTIC URAEMIC SYNDROME

- E. Coli produces the Shiga toxin which destroys blood cells and leads to HUS

30
Q

Coeliac disease: IgA Antibodies

A

Anti-tissue transglutinase (anti-TTG)

Anti-endomysial (anti-EMA)

31
Q

Coeliac diease: Presentation

A 
Often Asymptomatic- low threshold for testing 
Failure to thrive 
Diarrhoea 
Fatigue 
Weight loss 
Mouth ulcers 
Anaemia secondary to iron, B12 or folate deficiency 
Dermatitis herpetiformis
32
Q

What conditions are often linked to coeliac disease

A 
Type 1 diabetes
Thyroid disease 
Autoimmune hepatitis 
Primary biliary cirrhosis 
Primary sclerosing cholangitis 
Down’s syndrome
33
Q

Coeliac disease: Genetic association

A

HLA-DQ2 gene (90%)

34
Q

Coeliac disease: Diagnosis

A

Pt. Must remain on diet containing gluten !
Check total IgA levels (to exclude a deficiency)
Check coeliac specific antibodies (Anti-TTG, Anti-EMA)
Endoscopy and intestinal biopsy (Crypt hypertrophy, Villious atrophy)

35
Q

Complications of untreated coeliac disease

A 
Vitamin deficiency 
Anaemia 
Osteoporosis 
Ulcerative jejunitis 
Enteropathy-associated T-cell lymphoma of the intestine 
Non-Hodgkin Lymphoma 
Small bowel adenocardinoma (rare)
36
Q

Features of Crohn’s disease (NESTTS)

A

N - No blood or mucus (less common in crohns)
E - Entire GI tract
S - Skip lesions (on endoscopy)
T - Terminal ilium most affected
T - Transmural (full thickness) inflammation
S - Smoking is a risk factor (Don’t set the NEST on fire!)

37
Q

Ulcerative colitis characteristics (U-C- CLOSEUP)

A 
C - Continuous inflammation 
L- Limited to colon or rectum 
O - Only superficial mucosa affected
S - Smoking is preventative 
E - Excrete blood and mucus 
U - Use AMINOSALICYLATES
P - Primary sclerosing cholangitis
38
Q

Extra-intestinal manifestations of IBD

A 
Finger clubbing 
Erythema nodosum 
Pyoderma gangrenous 
Episcleritis and iritis 
Inflammatory arthritis 
Primary sclerosing cholangitis (UC)
39
Q

IBD: Investigations

A

Blood tests: Anaemia, infection, thyroid, kidney, LFT
FAECAL CALPROTECTIN - released by intestines when inflamed (more sensitive and specific in adults
Endoscopy (ODG and colonoscopy) with biopsy - gold standard
Imaging (Ultrasound, CT and MRI) - to look for any complications

40
Q

Crohns: Management - inducing remission

A

STEROIDS

Enteral nutrition: alternative to steroids in children where there are concerns about growth or side effects (taken orally, via NG tube, ND tube or NJ tube, or gastronomy)

If steroids don’t work alone —> immunosuppressant medication can be given: Azathioprine, infliximab, mercaptopurine, methotrexate, adalimumab

41
Q

Crohns: management - maintaining remission

A

Treatment tailored to individual patients
First line: Azathioprine, mercaptopurine
Alternatives: Methotrexate, infliximab, Adalimumab

42
Q

Crohns: Managment - surgery

A

If disease only affects distal ilium - possible to resect the area to prevent flares
Crohns typically affects entire GI tract - surgery used to treat strictures and fistulas secondary to the disease

43
Q

UC: Management - inducing remission

A

Mild to mod disease:
1st line: AMINOSALICYLATE ( e.g. mesalazine oral or rectal)
2nd line: CORTICOSTEROIDS (e.g. prednisolone)

Severe disease:
1st line: IV CORTICOSTEROIDS (e.g. hydrocortisone)
2nd line: IV CICLOSPORIN

44
Q

UC: management - maintaining remission

A

AMINOSALICYLATE (e.g. mesalazine oral or rectal)
AZATHIOPRINE
MERCAPTOPURINE

45
Q

UC: Management - surgery

A

UC only affects colon and rectum
Removing colon and rectum (panproctocolectomy) - removes disease
Permanent iliostomy or ilio-anal anastomosis (J-pouch)

46
Q

What is biliary atresia?

A

Congential condition
Bile duct narrowed or absent —> cholestasis (bile cannot be transported from liver to bowel
Unconjugated bilirubin therefore cant be excreted

47
Q

Biliary atresia: Presentation

A

Significant jaundice shortly after birth - HIGH LEVELS OF CONJUGATED BILIRUBIN
Suspect biliary atresia in babies with PERSISTANT JAUNDICE - lasting more than 14 days in term babies, and more than 21 days in pre-term babies

48
Q

Biliary atresia: Management

A

KASI PORTOENTEROSOMY
- attach a section of the small intestine to the opening of the liver (where the bile duct usually attaches)

Patients often require a full liver transplant to resolve the problem

49
Q

Causes of intestinal obstruction

A 
Meconium Ileus 
Hirschsprung’s disease 
Oesophageal atresia 
Duodenal atresia 
Intussusception 
Imperforate anus 
Mallo at ion of the intestines with a volvulus 
Strangulated hernia
50
Q

What is Intussusception

A

The bowel invaginates/ telescopes into itself

Thickens the overal size of the bowel and narrows lumen in the folded areas

51
Q

What conditions are Intussusception associated with ?

A 
Concurrent viral illness
Henoch-Schonlein Purpura 
Cystic fibrosis 
Intestinal polyps 
Meckles diverticulum
52
Q

Intussusception presentation

A 
Severe colicky abdo pain
Pale, lethargic and unwell child 
REDCURRENT JELLY STOOL 
RUQ mass on palpating (sausage shaped) 
Vomiting 
Intestinal obstruction
53
Q

Intussusception diagnosis

A

USS and contrast enema

54
Q

Intussusception management

A

THERAPEUTIC ENEMAS - force folded bowel back into right position
SURGICAL RESECTION - may be needed in enema doesn’t work, or if the bowel becomes gangrenous or perforated

55
Q

Peak incidence of appendicitis

A

Age 10-20

56
Q

Classic features of appendicitis

A

Central abdo pain that moves down to the RIF overtime and eventually becomes localised in the RIF
Tenderness at McBurney’s point (1/3 distance from ASIS to umbilicus)
Other features:
Anorexia, N&V, Rovsing’s sign (Palpation on LIF causes pain in RIF), Guarding on abdo palpation, Rebound tenderness, percussion tenderness (these 2 types of tenderness suggest peritonitis)

PAEDIATRICS (18 decks)

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