Gastrointestinal Flashcards
What timings of jaundice are particularly abnormal?
Less than 24 weeks and prolonged (>2 weeks)
In the first 24 hr of Jaundice what unconjugated causes of jaundice should you be most worried about?
Rh or ABO incompatibility
If >2wks unconjugated jaundice, what would be the most likely haem-related cause?
G6PD deficiency
What’s a risk for jaundice in all time frames?
Sepsis
What are some causes of conjugated jaundice?
TORCHES, Fructosemia, hepatitis, Biliary cysts or Biliary atresia, CF
What differentiates biliary atresia and choledochal cysts?
On U/S Atresia should non-dilated ducts and cysts show dilated ducts
What tests are vital when investigating jaundice?
Blood groups, Bilirubin, Direct Coombs, FBE
What is Alagille syndrome?
Autosomal dominant congenital syndrome that presents with Biliary atresia, Butterfly vertebrae and tetralogy of Fallot.
Vomitting at the end of paroxysmal cough?
Whooping cough
Viral causes of gastroenteritis and the biggest risk factor?
Rotavirus, Adenovirus, Norwalk virus
RF: Chidcare!
What age group does Toddler’s diarrhea affect?
6-36mo and ceases between 2-4 years.
Clinical presentation of Toddler’s Diarrhea?
Diagnosis of exclusion in a thriving child with excessive bowel movements. Diet may have excessive juices and may have diaper rash. Poo may have undigested particles
4 F’s for management of Toddler’s Diarrhea?
Fibre, Fluid intake, 35-40% Fat , Discourage Fruit juice!
Classic presentation of Lactase deficiency?
Chronic watery diarrhea and abdominal pain with associated bloating
Difference between Primary and secondary lactase deficiency?
In primary you begin life making plenty of lactase and all is good. But as you begin to replace milk with solids your lactase drops remarkably due to genetics. Hence classicly seen in older children
Secondary deficiency is in older infants with persistent diarrhea usually after post-viral/bacterial infection
Diagnosis of Lactase deficiency?
Trial of lactose free diet or Lactose tolerance test (measure glucose in blood after milk ingestion)
Watery stools and check stool pH (Lactose ferments into lactic acid) and check Hydrogen breath?
What is the clinical presentation of Milk protein allergy?
Presents during transitioning to formula with eczema and diarrhea. History of atopy
Management of Milk protein allergy?
Caesin hydrosylate and continue breastfeeding. Prescription amino acids. 80% of kids grow out of it by 3-4 years
What is post-gastroenteritis syndrome?
Re-introduction of normal diet after gastro leads to watery diarrhea - due to temporary lactose intolerance.
What is the peak period for GO reflux?
Peak at 4 months and resolution by 12mo
What is the pathophys for GO reflux?
The lower sphincter relaxes once the tummy is full – NORMAL developmental immaturity of lower oeseophaseal sphincter
Signs of GO reflux?
Effortless, back arching vomitting. Small volumes
What makes GOR GORD
FTT, food aversion, sleep problems, Haematemesis, Resp issues
When and how do we investigate GOR?
A thriving baby requires no investigation! Ix if Sx of GORD
Ix intraoesophageal pH study - Gold standard diagnosis
Mx of GOR/GORD?
Parental education
Conservative/: Thickened feeds, frequent and smaller feeds, postural
Meds: Consider Omeprazole or Ranitidine
Surgical: Indicated for failure of Medical therapy
Complications of GORD?
Oesophagitis, Barrett’s oesophagus, FTT, aspiration, oral feeding aversion
What’s the classic baby for Pyloric stenosis?
6-8wk, first bone male, early erythromycin exposure, caucasian
What is the pathophys behind Pyrloric Stenosis?
Pyloric circular muscle hypertrophy results in gastric outlet obstruction
What is a common complication of pyloric stenosis?
Hypovolaemia cause by emesis of gastric content causes hypochloremic, hypokalaemic (the body emits K+ in exchange to retainging H+) metabolic alkalosis
What is the classic clinical picture for Pyloric stenosis?
Projectile non-bilous vomitting (can be blood stained)
Vomiting after feeds and still hungry afterwards!
Possible FTT
Examination findings in Pyloric Stenosis?
Smooth olive shaped mass in RUQ, Gastric peristalsis
What investigations need to be done in a baby with Pyloric stenosis?
Electrolytes,
U/S is diagnostic! Pyloric length 14>mm and thickness >4mm
Management of Pyloric Stenosis?
Fluid resusc, (try NG tube), Ondansetron, Correct electrolytes, Surgery
Whats the specific surgery in Pyloric stenosis?
Ramstedt’s Pyloromyotomy - within 24 hrs of stabilisation!
What is the most common cause of intestinal obstruction in infants after the neonatal period?
Intussusception!
What ages are affected by intussusception?
3mo - 2yr (peak age). More common in males - physiological lead points - Peyer’s patch
Pathological lead point - >3yo (Meckel’s, TB, HSP, Lymphoma)
What is intussusception?
It is invagination of the proximal bowel into a distal segment. most commonly involving ileum and caecum.
Triad for Intussusception?
Redcurrant jelly stools + Sausage shaped mass in abdomen + episodic crying (Colicky abdominal pain)
Classic presentation of Intussusception?
Paroxysmal, severe, colicky pain and pallor.
Bile stained vomitting (late sign), Passing of reducrrant jelly stools (signs of ischaemia)
Symptoms often following Viral infection!
What do you see on examination of Intussusception?
Sausage shaped mass palpable in the Hypochondrium, Pale and lethargic, Distended bowel!
What Ix in Intussusception?
U/S is diagnostic - a targert sign!
AXR to r/o bowel perforation, Bloods (FBE, UEC, Group and hold)
Management of intussecpition?
Operative mx if Peritonitis or pathological leads!
Otherwise, immediate fluids, and urgent reduction. Reduction via air-contrast enema for non-pathological leads.
What are some complications of Intussusception?
Stretching and constriction of the mesentery resulting in venous obstruction, causing engorgement and bleeding from the bowel mucosa, fluid loss and subsequently bowel perforation, peritonitis and gut necrosis.
What syndrome is Tracheo-oesophageal fistula associated with?
VACTERL
What is VACTERL?
Vertebral dysgenesis Anal Atresia Cardiac anomalies Trcheo-oesophageal fistula/Oesophageal atresia Renal Anomalies Limb anomalies
What is a maternal history of polyhydramnios related to?
T-O fistula
What is the classic presentation of T-O fistula?
Non-bilous vomitting, cyanosis after feeding, respiratory distress, recurrent pneumonia
Frothy bubbles of mucous in mouth and nose.
NG tube curled up in pouch?
T-O fistula!
Mx of T-O fistula?
Look for other anomalies. Fix this one!
What is gastrochosis?
This is a defect of the abdominal wall, with free extrusion of intestine into amniotic cavity. There is no specific environmental factor identified. Defect in embryogenesis is unclear
What is the primary difference between Gastrochisis and Omphalocele?
Omphalocele has the potruding organs in a bag
What findings are seen on examination with Gastrochisis?
Hollow viscera - stomach, S/L bowel.
Defect lateral to chord (usually right). Bowel may be inflamed, thickened and foreshortened.
Mx of Gastrochisis?
NG decompression, IV fluids and Abx
Keep viscera moist and protected until surgical reduction with primary abdominal closure or staged closure with silo. May have bowel dysmotility requiring motility medications
What are risk factors for Omphalocele and Gastrochisis?
More risk with lower gestational age, increased maternal age, M:F = 3:2. Antental diagnosis.
What extrusion is seen in omphalocele?
Defect of abdominal wall, with extrusion of sac covered viscera (amnion, Wharton’s jelly, peritoneum)
30-70% of Omphalocele is associated with genetic syndromes. Which ones?
Pentology of Cantrell, congenital heart disease, Beckwith-Wiedermann syndrome
Also associated with Pulmonary hypoplasia
How to close a M(2-4cm)/L (>4cm) Omphalocele?
Best treated with silver sulfadiazine to promote epitheliasation coupled with compression dressing to allow gradual reduction, followed by future repair with or without mesh
What is Meckel’s diverticulum?
Most common remnant of vitelline duct that connects the yolk sac with primitive gut.
What is the rule of 2’s with Meckel’s ? (8)
2% of the popn. 2:1 Male to female Often present by 2yr of age! Symptomatic in 2% of cases Found within 2 feet (10-90cm) of the ileocaecal vlave 2 inches in length 2 inches in diameter Made up of 2 types of tissue - gastic and pancreatic
What is the pathophys of Meckel’s diverticulum?
Failure of vitelline duct to regress 5-7wk in utero; 50% contain heterotopic tissue (e.g. gastric mucosa, ectopic pancreas)
What is the role of Vitellointestine duct in a foetus?
The GI in baby is connected to the umbilical through this tract to the umbilical for excretion of wastes
What are some clinical features of Meckel’s?
- Bright red blood per rectum (hetero-ectopic gastric mucosa in Meckel’s causing mucosal ulceration and bleeding in adjacent small bowel mucosa – due to production of enzymes)
- Abdominal sepsis (meckel’s diverticulitis +/- perforation)
- Small bowel volvulous around fibrous band
What Ix used to identify Meckel’s?
AXR, Meckel scan - scan for ectopic tissue with Technetium Tc99m - identifies gastric mucosa
Bilous vomiting in infant is a life threatening emergency secondary to __________ until proven otherwise
Midgut Volvulus
What are other abnormalities related to Meckel’s?
Omphalomesenteric fistula, umbilical sinus, umbilical cyst, fibrous band
What is the job of the Vitellointestinal duct?
The GI in baby is connected to the umbilical through this tract to the umbilical for excretion of wastes
What is the clinical presentation of Meckel’s?
o Bright red blood per rectum (hetero-ectopic gastric mucosa in Meckel’s causing mucosal ulceration and bleeding in adjacent small bowel mucosa – due to production of enzymes)
o Abdominal sepsis (meckel’s diverticulitis +/- perforation)
o Small bowel volvulous around fibrous band
Most common cause of Gastro?
Rotavirus
How do you investigate Acute Gastro?
Stool MCS and PCR
Investigations for coeliac disease?
Anti-gliadin, anti-endomysial, ant-tissue transglutaminase, IgA, Small bowel biopsy
Abdominal pain, pubertal delay, erythema nodosum, LOW +/- Diarrhea
Inflammatory bowel disease
Newborn Jaundice, with splenomegaly, retinitis, purpura and derranged LFT’s
CMV
Ix for Neonatal jaundice?
BSL, SBR (Serum Bilirubin Ratio), FBE and blood film, CRP and Blood culture, Blood groups + Coombs
Conjugated Jaundice with Contracted Gallbladder on U/S
Biliary atresia
Jaundice: Dilated bile ducts
Choledocal cyst
Alagille syndrome with butterfly vertebra and pulmonary stenosis is related to _______
Biliary atresia
Double bubble sign on AXR
Duodenal atresia
Duodenal Atresia is associated with ______
Trisomy 21
