Gastrointestinal Flashcards
What are the medical causes of abdominal pain
Constipation
UTI
Coeliac disease
IBD
IBS
Mesenteric adenitis
Abdominal migraine
Pyelonephritis
Henoch-Schonlein purpura
Tonsillitis
Diabetic ketoacidosis
Infantile colic
What are the medical causes of abdominal pain specific to teenage girls
Dysmenorrhoea
Mittelschmerz
Ectopic pregnancy
PID
Ovarian torsion
Pregnancy
What are the surgical causes of abdominal pain
Appendicitis
Intussusception
Bowel obstruction
Testicular torsion
What are the red flags for abdominal pain
Persistent or bilious vomiting
Severe chronic diarrhoea
Fever
Rectal bleeding
Weight loss
Faltering growth
Dysphagia
Night time pain
Abdominal tenderness
What is the management for recurrent abdominal pain
Careful explanation
Reassurance
Distract child
Advise parents not to ask about pain
Probiotic supplements
Avoid NSAIDs
What are abdominal migraines
Central abdominal pain lasting more than 1 hour
Associated with: nausea, vomiting, anorexia, pallor, headaches, photophobia, aura
What is the management for acute attacks of abdominal migraine
Low stimulus environment
Paracetamol
Ibuprofen
Sumatriptan
What is the preventative management for abdominal migraines
Pizotifen (serotonin antagonist)
Propranolol
Cyproheptadine (antihistamine)
Flunarizine (CCB)
How might a child with constipation present
< 3 stools per week
Hard stools, difficult to pass
Rabbit dropping stools
Straining
Pain on passing stool
Abdominal pain
Abnormal posture
Rectal bleeding
Faecal impaction
Overflow diarrhoea
Hard stool palpable in abdomen
Loss of sensation of need to open bowels
What are the red flags for constipation
Not passing meconium within 48 hours
Neurological signs or symptoms
Vomiting
Ribbon stool (anal stenosis)
Abnormal anus
Abnormal lower back or buttocks
Failure to thrive
Acute severe abdominal pain and bloating
What is encopresis
Faecal incontinence
Not pathological until age 4
Sign of chronic constipation
What are the lifestyle factors contributing to constipation
Habitually not opening bowels
Low fibre intake
Poor fluid intake and dehydration
Sedentary lifestyle
Psychosocial problems
What is the management for constipation
Correct reversible contributing factors
High fibre diet
Good hydration
Laxatives (movicol first line)
Disimpaction (high dose laxatives)
Encourage and praise visiting toilet
What are the complications of constipation
Pain
Reduced sensation
Anal fissures
Haemorrhoids
Overflow and soiling
Psychosocial morbidity
What is gastro-oesophageal reflux
Contents of stomach reflux through lower oesophageal sphincter
Babies have immature LOS
Normal for babies for have GOR until age 1
How might a patient with gastro-oesophageal reflux present
Chronic cough
Hoarse cry
Distress, crying, or unsettled after feed
Reluctant to feed
Pneumonia
Poor weight gain
Over 1s: heartburn, acid regurgitation, retrosternal or epigastric pain, bloating, nocturnal cough
What is the general advice given to parents of babies with gastro-oesophageal reflux
Small, frequent meals
Burping after feeds
Not over-feeding
Keep baby upright after feed
What management can be used in problematic cases of gastro-oesophageal reflux
Gaviscon mixed with feeds
Thickened formula or milk
Ranitidine
Omeprazole
What is Sandifer’s syndrome
Associated with gastro-oesophageal reflux
Resolves as reflux resolves
Get torticollis (forceful contraction of neck muscles, twisting of neck) and dystonia (abnormal muscle contractions)
What is pyloric stenosis
Hypertrophy of pyloric sphincter
Prevents food from travelling from stomach to duodenum
Get forceful peristalsis of stomach
Have projectile vomiting
How might a patient with pyloric stenosis present
Hungry baby
Projectile vomiting
Thin
Pale
Failure to thrive
Hypertrophic muscle of pylorus on abdominal palpation
Hypochloremic metabolic alkalosis on blood gas
What investigation is needed in pyloric stenosis
Abdominal ultrasound (thickened pylorus)
What is the management for pyloric stenosis
Laparoscopic pyloromyotomy (incision of pyloric smooth muscle)
What is gastroenteritis
Inflammation of stomach and intestines
Nausea, vomiting, diarrhoea
Common in children
Usually viral
Need to isolate patients
Main concern in dehyrdration
What are the differentials for diarrhoea
Gastroenteritis
IBD
Lactose intolerance
Coeliac disease
Cystic fibrosis
Toddler’s diarrhoea
IBS
Antibiotics
What are the causes of viral gastroenteritis
Rotavirus
Norovirus
Adenovirus
What are the causes of bacterial gastroenteritis
E coli
Campylobacter jejuni
Shigella
Salmonella
Bacillus cereus
Yersinia enterocolitica
Staph aureus toxin
What are the investigations for gastroenteritis
Stool microscopy, culture and sensitivity
What is the management for gastroenteritis
Good hygiene
Barrier nursing
Infection control
Stay off school for 48 hours after resolution
Maintain hydration
Avoid antidiarrhoea and antiemetic medications
Antibiotic use guided by sensitivity testing
What are the complications of gastroenteritis
Lactose intolerance
IBS
Reactive arthritis
Guillain-Barre syndrome
What is coeliac disease
Gluten exposure causes inflammation of small intestine
Usually develops in early adulthood
Key autoantibodies: anti-TTG, anti-EMA
Autoantibody levels correspond with disease severity
Mainly affects jejunum
Closely linked with type 1 diabetes
How might a patient with coeliac disease present
Often asymptomatic
Failure to thrive
Diarrhoea
Fatigue
Weight loss
Mouth ulcers
Anaemia
Dermatitis herperiformis (itchy rash on abdomen)
Neurological symptoms (peripheral neuropathy, cerebellar ataxia, epilepsy)
What investigations are needed for coeliac disease
To be investigated when patients still eating gluten
Total IgA levels
Coeliac-specific antibodies (anti-TTG, anti-EMA)
Endoscopy and intestinal biopsy (crypt hypertrophy, villous atrophy)
What is the management for coeliac disease
Lifelong gluten free diet
What are the complications of coeliac disease
Vitamin deficiency
Anaemia
Osteoporosis
Ulcerative jejunitis
Non-Hodgkin lymphoma
Small bowel adenocarcinoma
How might a patient with inflammatory bowel disease present
Profuse diarrhoea
Abdominal pain
Bleeding
Weight loss
Anaemia
Systemically unwell during flare ups
What are the characteristic features of Crohn’s disease
NESTS
No blood or mucus
Entire GI tract
Skip lesions on endoscopy
Terminal ileum affected, transmural
Smoking is a risk factor
What are the characteristic features of ulcerative colitis
CLOSE-UP
Continuous inflammation
Limited to colon and rectum
Only superficial mucosa affected
Smoking is protective
Excrete blood and mucus
Use aminosalicylates
Primary sclerosing cholangitis
What are the extra-intestinal manifestations of inflammatory bowel disease
Clubbing
Erythema nodosum
Episcleritis and iritis
Inflammatory arthritis
Primary sclerosing cholangitis
What investigations are needed for inflammatory bowel disease
Bloods
Faecal calprotectin
Endoscopy with biopsy (gold standard)
Imaging to look for complications
What is the management for Crohn’s disease
Inducing remission:
- Steroids (oral prednisolone, IV hydrocortisone)
- Immunosuppressants
Maintaining remission:
- Immunosuppressants
Surgery
What is the management for ulcerative colitis
Inducing remission:
- Corticosteroids
Maintaining remission:
- Aminosalicylate, azathioprine
Surgery
What is biliary atresia
Section of bile duct narrowed or absent
Get cholestasis
Get prevention of excretion of conjugated bilirubin
How might a patient with biliary atresia present
Shortly after birth
Significant jaundice (high conjugated bilirubin levels)
Lasting jaundice (> 14 days in term babies, >21 days in preterm babies)
What investigations are needed for biliary atresia
Serum conjugated and unconjugated bilirubin levels (expect high levels of conjugated form)
What is the management for biliary atresia
Surgery (Kasai protoenterostomy, attach section of small intestine to opening of liver)
Liver transplant
What does intestinal obstruction lead to
Vomiting
Absolute constipation
How might a patient with intestinal obstruction present
Persistent vomiting (may have bright green bile)
Abdominal pain and distension
Failure to pass stool or wind
Abnormal bowel sounds
What are the causes of intestinal obstruction
Meconium ileus
Hirschsprung’s disease
Oesophageal atresia
Duodenal atresia
Intussusception
Imperforate anus
Volvulus
Strangulation hernia
What investigation is needed for bowel obstruction
Abdominal X-ray
What is the management for bowel obstruction
Keep NBM
Insert NG tube
IV fluids
Surgery
What is Hirschsprung’s disease
Congenital condition
Nerves of myenteric plexus absent in distant bowel and rectum
Length of colon without innervation can vary
Aganglionic section of bowel not able to relax
Loss of movement of faeces
Get intestinal obstruction
What conditions are associated with Hirschsprung’s disease
Down’s syndrome
Neurofibromatosis
Multiple endocrine neoplasia type II
How might a patient with Hirschsprung’s disease present
Acute intestinal obstruction shortly after birth
Delayed meconium passing
Chronic constipation since birth
Abdominal pain and distension
Vomiting
Poor weight gain
Failure to thrive
What is Hirschsprung’s-associated enterocolitis
Inflammation and obstruction of intestines
20% of neonates with Hirschsprung’s
Life threatening
Within 2-4 weeks of birth
Presentation: fever, abdominal distension, diarrhoea, features of sepsis
Can lead to toxic megacolon and perforation of bowel
Management: urgent antibiotics, fluid resuscitation, decompression of obstruction
What are the investigations for Hirschsprung’s disease
Abdominal X-ray (for obstruction)
Rectal biopsy (absence of ganglionic cells)
What is the management for Hirschsprung’s disease
IV antibiotics (if have enterocolitis)
Surgical removal of aganglionic bowel
What is intussusception
Bowel invaginated and telescopes into itself
More common in boys
Usually at 6 months - 2 years
What are the conditions associated with intussusception
Concurrent viral illness
Cystic fibrosis
Intestinal polyps
Meckel diverticulum
How might a patient with intussusception present
Severe, colicky abdominal pain
Pale, lethargic, unwell child
Redcurrant jelly stools
RUQ mass (sausage shaped)
Vomiting
Intestinal obstruction
What are the investigations for intussusception
Ultrasound
Contrast enema
What is the management for intussusception
Therapeutic enemas
Surgical reduction
Surgical resection of bowel (if gangrenous or perforated)
What are the complications of intussusception
Obstruction
Gangrenous bowel
Perforation
Death
How might a patient with appendicitis present
Central abdominal pain, then localises to right iliac fossa
Tenderness over McBurney’s point (1/3 from anterior superior iliac spine to umbilicus)
Loss of appetite
Nausea and vomiting
Rovsing’s sign (palpating LIF causes pain in RIF)
Guarding
Rebound tenderness
Percussion tenderness
What are the investigations for appendicitis
Raised inflammatory markers
CT scan
Diagnostic laparoscopy
What are the key differentials for appendicitis
Ectopic pregnancy
Ovarian cyst
Meckel’s diverticulum
Mesenteric adenitis
Appendix mass
What is the management for appendicitis
Appendicectomy
Laparoscopic surgery
