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Paediatrics > Gastrointestinal > Flashcards

Gastrointestinal Flashcards

1
Q

What types of vomiting can a child experience?

A
  • Vomiting with Wretching
  • Projectile vomiting
  • Billous vomiting
  • Effortless vomiting
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2
Q

What is possetting?

A

Small amount of regurgitated milk which often accompanies expulsion of swallowed air

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3
Q

How does possetting differ from regurgiation?

A

Regurgitation is larger volumes resulting in bigger volume losses

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4
Q

Why is regurgitation important whereas possetting not?

A

Pssetting occurs in nearly all babies, whereas regurgitation could indicate the presence of GORD

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5
Q

What are the phases of the vomiting reflex?

A
  1. Pre-ejection - Pallor, nausea, Tachycardia
  2. Ejection - Retch, Vomit
  3. Post-ejection - Weakness, shivering, lethargy
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6
Q

What are the red flags in a vomiting child?

A
  • Bilious vomiting
  • Haematemesis
  • Projectile vomiting
  • Coughing after paroxysmal coughing
  • Abdominal tenderness/pain on movement
  • Abdominal distention
  • Hepatospenomegaly
  • Bloody stool
  • Shock/severe dehydration
  • Bulging fontanelle/seizures
  • Faltering Growth
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7
Q

What does bile stained vomit suggest?

A

Intestinal obstruction

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8
Q

What would haematemesis suggest?

A
  • Oesophagitis
  • Peptic ulcer
  • Oral/nasal bleeding
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9
Q

What would projectile vomiting suggest?

A

Pyloric stenosis

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10
Q

What would vomiting after paroxysmal coughing suggest?

A

Pertussis

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11
Q

What would vomiting with abdominal tenderness/pain on movement suggest?

A

Surgical abdomen

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12
Q

What would vomiting with abdominal distention suggest?

A

Intestinal obstruction

(incl. strangulated inguinal hernia)

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13
Q

What would vomiting with hepatosplenomegaly suggest?

A

Chronic liver disease

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14
Q

What would vomiting with blood in the stool suggest?

A
  • Intussuception
  • Gastroenteritis - salmonella or campylobacter
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15
Q

What are possible causes of vomiting with severe dehydration/shock in a child?

A
  • Pyloric stenosis
  • Severe gastroenteritis
  • Systemic infection - UTI, meningitis
  • Diabetic ketoacidosis
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16
Q

What would vomiting with seizures/bulging fontanelles suggest?

A

Raised ICP

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17
Q

What would vomiting with faltering growth suggest?

A
  • GORD
  • Coeliac disease
  • Other GI conditions - IBD etc
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18
Q

What can cause vomiting in infants?

A
  • Pyloric stenosis
  • GORD
  • Feeding problems
  • Infection - gastroenteritis, respiratory, pertussis, UTI, Meningitis
  • Dietary Protein Intolerance
  • Intestinal obstruction
  • Inborn metabolic problems
  • Renal failure
  • Congenital adrenal hyperplasia
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19
Q

What can cause intestinal obstruction in infants?

A
  • Pyloric stenosis
  • Duodenal atresia
  • Intussuception
  • Malrotation
  • Volvulus
  • Strangulated inguinal hernia
  • Hirschprungs disease
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20
Q

What can cause vomiting in pre-school children?

A
  • Gastroenteritis
  • Infection - resp tract, otitis media, UTI, pertussis, meningitis
  • Appendicitis
  • Intestinal obstruction
  • Raised ICP
  • Coeliac disease
  • Renal failure
  • Inborn errors of metabolism
  • Torsion of the testis
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21
Q

What can cause intestinal obstruction in pre-school children?

A
  • Intusucception
  • Malrotation
  • Volvulus
  • Adhesions
  • Foreign Body - bezoar
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22
Q

What can cause vomiting in school age and adolescents?

A
  • Gastroenteritis
  • Infection - including pyelonephritis, speticaemia, meningitis
  • Peptic ulcer/H. Pylori infection
  • Appendicitis
  • Migraine
  • Raised ICP
  • Coeliac disease
  • Renal failure
  • Diabetic ketoacidosis
  • Alcohol/drugs
  • Cyclical vomiting syndrome
  • Bulimia/anorexia nervosa
  • Pregnancy
  • Torsion of the testicle
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23
Q

What is GORD?

A

Gastro-oesophageal reflux

Involuntary passage of gastric contents into the oesophagus

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24
Q

What can contribute to the developement of GORD in children?

A
  • Relatively liquid diet
  • Horizontal posture
  • Short intra-abdominal oesophagus
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25
Q

What is the general progression of GORD in a child?

A

Normally resolves by 12 months - upright posture, mature lower oesophageal sphincter and solid diet

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26
Q

What are the complications of GORD?

A
  • Faltering growth
  • Oesophagitis
  • Recurrent aspiration -> Pneumonia
  • Dystonic neck posturing
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27
Q

What groups of children is severe reflux more common in?

A
  • CP or other neurodevelopmental disorders
  • Preterm infants
  • Post surgery - oesophageal atresia/diaphragmatic hernia
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28
Q

If you suspected GORD, how would you go about confirming diagnosis?

A

Usually clinically, or:

  • Video fluoroscopy
  • Barium swallow
  • Milk scan
  • pH/impedence monitoring
  • Endoscopy
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29
Q

How can children with GORD present?

A
  • GI - vomiting, haematemesis
  • General - Faltering growth, feeding problems
  • Resp - apnoea, wheeze, cough, chest infection
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30
Q

What should you consider as a differential diagnosis if a child is presenting with GORD like symptoms?

A

Cow’s milk allergy

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31
Q

How would you approach managing a child with GORD?

A

Determine complexity, then

  • Feeding advise
    • Parental reassurance
    • Feeding/post feeding position
    • Adjust feeding volumes
  • Nutritional support
    • Thickener
    • Pro-kinetic
    • Acid suppression
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32
Q

In children with GORD which is unresponsive to conservative or medical treatment, what else can be done?

A

Nissen fundoplication

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33
Q

What would indicate the need for fundoplication in a child with GORD?

A
  • No response to treatment
  • Oesophagitis
  • Faltering growth
  • Aspiration
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34
Q

What is pyloric stenosis?

A

Hypertrophy of the pyloric sphincter causing gastric obstruction

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35
Q

What age does pyloric stenosis present?

A

4-12 weeks

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36
Q

What sex is more commonly affected by pyloric stenosis?

A

Boys (4:1)

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37
Q

What would suggest that a child had pyloric stenosis?

A
  • Projectile vomiting - Non-billous, straight after feeding, no diarrhoea
  • Dehydration/Shock
  • Weight loss
  • Constipation - from dehydration
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38
Q

What is the classical electrolyte disturbance seen in pyloric stenosis?

A

Hypokalaemic Hypochloraemic Metabolic Alkalosis

Vomiting -> loss of hydrochloric acid (hydrogen and chloride ions) with the stomach contents. Severe vomiting -> loss of potassium (hypokalaemia) and sodium (hyponatremia). The kidneys compensate for these losses by retaining sodium in the collecting ducts at the expense of hydrogen ions (sparing sodium/potassium pumps to prevent further loss of potassium), leading to metabolic alkalosis.

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39
Q

What would you see on examination if a child had pyloric stenosis?

A
  • Observe left-to-right LUQ peristalsis during feed
  • Palpation of olive sized mass in RUQ
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40
Q

What investigations would you do if you suspected a child had pyloric stenosis?

A
  • Bloods - U&E’s for electrolyte disturbance
  • Imaging - US for thickened pylorus
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41
Q

How would you manage a child with pyloric stenosis?

A
  1. Fluid resus (0.45% saline, 5% dextrose + KCl)
  2. NG tube - if stomach is overinflated with air, also for post operative feeding
  3. Pyloromyotomy (Ramstedt’s)
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42
Q

What is intusucception?

A

Invagination of proximal bowel into distal segment (commonly ileum into caecum)

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43
Q

What is the most serious complication of intussusception?

A

Stetching and constriction of the mesentery -> venous obstruction -> engorgement and bleeding of mucosa -> fluid loss, perforation -> peritonitis, gut necrosis

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44
Q

What age does intussusception most commonly occur?

A

3 months - 2 years

Can occur at any age

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45
Q

How does intussusception present?

A
  • Paroxysmal Colic pain with episodic, painful crying - pale, draws legs up
  • Vomiting/Not feeding
  • Sausage shaped mass - in abdomen; RF, transverse colon
  • Red current jelly stool - late presentation
  • Abdominal distention
  • Shock
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46
Q

What is thought could be a cause of intussusception?

A

Viral infection of peyer’s patch, which causes enlargement and forms a lead point

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47
Q

What is more likely to be a lead point in a child over 2 with intussusception?

A
  • Meckel’s diverticulum
  • Polyp
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48
Q

How would you investigate for suspected intussusception?

A

US Scan - look for target sign

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49
Q

How would you treat intussusception?

A
  • Pneumostatic reduction (air enema)
  • Laparascopic surgery
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50
Q

When is surgery most likely to be required in managing intussusception?

A

Peritonitis or unsuccessful air enema

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51
Q

What is Meckel’s Diverticulum?

A

Ileal remnent of the vitello-intestinal duct which contains ectopic gastric or pancreatic tissue

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52
Q

How does Meckel’s diverticulum present?

A

Asymptomatic

or

Severe rectal bleeding

Can also present as intussusception, volvulus or diverticulitis

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53
Q

How would you treat Meckel’s Diverticulum?

A

Surgical resection

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54
Q

What is the definition of chronic diarrhoea?

A

4 or more stools per day for more than 4 weeks

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55
Q

What is the definition of acute diarrhoea?

A

< 1 week

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56
Q

What is the defintion of persistent diarrhoea?

A

2-4 weeks

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57
Q

What are the different types of diarrhoea?

A
  • Osmotic
  • Secretory
  • Inflammatory
  • Altered motility
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58
Q

How does osmotic diarrhoea occur?

A

Movement of water into the bowel to equilibrate osmotic gradients

Uually a feature of malabsorptive diarrhoea

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59
Q

How does secretory diarrhoea occur?

A

Toxins switch on ion channels which in turn facilitate excessive water loss

Classically associated with toxin production from Vibrio cholerae and enterotoxigenic Escherichia coli

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60
Q

How does inflammatory diarrhoea occur?

A
  • Malabsorption due to intestinal damage
  • Secretory effect of cytokines
  • Accelerated transit time in response to inflammation
  • Protein exudate across inflamed epithelium
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61
Q

What is a simple way to distinguish between secretory and osmotic diarrhoea?

A

Fasting test - if diarrhoea stops on fasting, then can assume it is osmotic

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62
Q

What is infant colic?

A

Common symptom complex which occurs in first few months of life and normally resolves by 4 months

Causes paroxysmal inconsolable crying often accompanied by drawing up of the knees and passage of excessive farts

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63
Q

What would you be thinking in a child that had persistent infant colic?

A
  • Cow’s milk protein allergy
  • GORD
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64
Q

What is abdominal migraine?

A

Abdominal pain in addition to headaches

Can be associated with vomiting and facial pallor

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65
Q

What is recurrent abdominal pain definned as?

A

Pain sufficient to interupt normal daily activities and last at least 3 months

Pain is often periumbilical

A cause is identified in <10% of cases

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66
Q

What gastrointestinal problems could cause recurrent abdominal pain?

A
  • IBD/IBS
  • Constipation
  • Non-ulcer dyspepsia
  • Abdominal Migraine
  • Gastritis/peptic ulceration
  • Malrotation
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67
Q

What gynaecological problems would you think of in a girl with recurrent abdominal pain?

A
  • Pregnancy
  • Dysmennorhoea
  • Ovarian cyst
  • PID
68
Q

What urinary tract problems would you consider in a child with recurrent abdominal pain?

A
  • UTI
  • PUJ obstruction
69
Q

What hepatobiliary problems would you consider in a child with recurrent abdominal pain?

A
  • Gallstones
  • Hepatitis
  • Pancreatitis
70
Q

What symtpoms or signs suggest an organic cause in recurrent abdominal pain?

A
  • Epigastric pain at night - duodenal ulcer
  • Diarrhoea, Weight loss, growth failure, blood in stools - IBD
  • Vomiting - pancreatitis
  • Jaundice - liver disease
  • Dysuria, 2o eneuresis - UTI
  • Billous vomiting and abdominal distention - Intussusception
71
Q

What is the most common cause of gastroenteritis in the developed world??

A

Rotavirus

72
Q

Besides rotavirus, what are other viral causes of gastroenteritis in children?

A
  • Adenovirus
  • Norovirus
  • Coronavirus
73
Q

Which more commoly cause of gastroenteritis, viruses or bacteria?

A

Viruses

74
Q

What bacterial infections can cause gastroenteritis?

A
  • Campylobacter jejuni
  • Shigella
  • Salmonella
  • E. Coli
75
Q

What are the common presenting symptoms in gastroenteritis in children?

A
  • Loose/watery stool
  • Vomiting
  • Abdominal pain
  • Dehydration - if profuse
76
Q

What is the most serious complication of gastroenteritis?

A

Dehydration leading to shock

77
Q

What types of children are at increaed risk of dehydration?

A
  • Infants
  • > 6 stools in last 24 hours
  • 3 or more vomits in last 24 hours
  • Unable to tolerate fluids
  • Malnourished
78
Q

What are the basal fluid requirements of children on a daily basis?

A

100-120ml/kg/day

79
Q

Why are infants so at risk of dehydration?

A
  • Increased SA:volume ratio
  • Higher fluid requirements
  • Immature renal tubules
80
Q

What clincal red flags would indicate that a child is clinically dehydrated?

A
  • Decreased level of consiousness
  • Dry mucous membranes
  • Sunken eyes with no tears
  • Decreased urine output
  • Tachycardia/tachypnoea
  • Reduced skin turgor
81
Q

What clinical features may you see in a child who is in hypovolaemic shock due to dehydration?

A
  • Decreased level of consiousness
  • Decreased urine output
  • Pale or mottled skin
  • Cold extremities
  • Grossly sunken eyes
  • Dry mucous membranes
  • Tachypnoea/tachycardia
  • Weak pulses
  • Slowed cap refill
  • Hypotension
82
Q

What is isonatraemic dehydration?

A

When sodium and water loss are equal, meaning plasma sodium remains largely unchanged

83
Q

What is hyponatraemic dehydration?

A

Greater loss of sodium, meaning that plasma sodium drops. This leads to shift of fluid from extra- to intra-cellular compartments.

If this occurs in the brain, brain volume increases -> convulsions

Greater degree of shock per unit water loss due to reduction in extracellular volume

84
Q

What can cause hyponatraemic dehydration?

A

Diarrhoea in a child where they drink water or hypotonic drink

85
Q

What is hypernatraemic dehydration?

A

Water loss exceeds sodium loss, meaning that plasma sodium increases. This leads to a shift of fluid into the ECF. This means that signs of fluid depletion are less per unit fluid loss - less easy to see this form of dehydration clinically

86
Q

Why is hypernatraemic dehydration dangerous?

A

Leads to cerebral shrinkage -> jittery, increased muscle tone, hyperreflexia, altered consciousness, seizures and multiple cerebral haemorrhages

Transient hyperglycaemia also occurs

87
Q

How would you investigate in a child with suspected gastroenteritis?

A
  • Normally no investigations - based on clinical presentation
  • Stool culture - septic, blood or immunocompromised
  • Bloods - U&Es, creatinine, glucose
88
Q

How would you treat a child who was dehydrated but showed no clincal signs of dehydration?

A
  • Continue breastfeeding
  • Encourage fluid intake
  • Discourage fruit juice and carbonated drinks
  • Offer ORS if risk of dehydration
89
Q

How would you treat a child displaying clinical signs of dehydration?

A
  • ORT (50ml/kg over 4 hours) + small amount of maintenance fluid (with dioralyte)
  • Continue breast feeding
  • ORS via NG tube if intake poor
  • IV fluids if clinically deteriorates
90
Q

How would you treat a child in clinical shock from dehydration caused by gastroenteritis?

A

IV Fluid bolus - 20ml/kg - Repeat until symptoms improve. If not, call for help

If symptoms improve:

  • IV therapy - calculcate maintenance ( using values below), and add fluid deficit (100 ml/kg/day if shocked)
    • First 10kg - 100ml/kg/day
    • Second 10kg - 50 ml/kg/day
    • >20kg - 20ml/kg/day
91
Q

How would you treat hypernatraemic dehydration?

A

**Aim to reduce plasma sodium at rate of <0.5 mmol/l per hour - may result in cerebral oedema and seizures if too quick

  • Isotonic solution
  • Replace fluid deficit over 48 hrs
92
Q

What would you give a child once they had been rehydrated following dehydration caused by gastroenteritis?

A

ORS 5ml/kg for every large watery stool if still having symptoms

93
Q

In a child who is being rehydrated, what nutritional considerations do you have to consider?

A
  • Continue breast feeds - where possible
  • Encourage oral fluids but not solids
  • Avoid carbonated drinks
94
Q

In a child who has been rehydrated, what nutritional considerations would you have to make?

A
  • Normal diet, milk and solids
  • Avoid fruit juices and carbonated drinks until resolved
95
Q

What are red flag signs in a child with gastroenteritis?

A
  • Temperature
  • Tachypnoea
  • Altered consciousness
  • Neck stiffness
  • Blood in stool
  • Bilious vomiting
  • Severe or localised abdominal pain
  • Abdominal distention
96
Q

What can happen following an episode of gastro-enteritis?

A

Post-gastroenteritis syndrome

Temporary intolerances (e.g. lactose)

97
Q

What is important about nocturnal diarrhoea?

A

It is always pathological

98
Q

How long does diarrhoea normally last?

A

5-7 days, resolves by 2 weeks

99
Q

How long does vomiting normally last?

A

1-2 days, resolves 3 days

100
Q

What are early signs of dehydration?

A
  • Thirst
  • Sunken eyes
  • Reduced skin turgor
101
Q

If a child has vomiting and diarrhoea, what would you want to rule out when taking history and examination, and considering what investigaitons to preform?

A

Serious systemic infection - sepsis, meningitis, UTI

102
Q

Why do you give 100ml/kg/day for first 10kg, 50ml/k/day for 2nd 10kg, etc. instead of using the 4, 2, 1 formula?

A

To correct for fluid deficit from dehydration

103
Q

For a child in shock from dehydration, how much extra fluid would you give in maintenance fluid to correct for fluid deficit?

A

100ml/kg

104
Q

If a child is not clinically shocked from dehydration, how much extra fluid would you give in maintenance fluids within the first 24 hours to correct for fluid deficit?

A

50ml/kg

105
Q

How would a child with a malabsorptive disorder present?

A
  • Abnormal stools
  • Faltering growth
  • Specific nutrient deficiency
106
Q

What is coeliac disease?

A

Enteropathy in which gliadin fraction of gluten molecule provokes a dmaaging immunological reaction in the proximal small intestine

Rate of migration of entrerocytes from crypts is massively increased but is insufficient for rate of cell loss at top of villi -> villous atrophy

107
Q

What is the prevalence of coeliac disease?

A

1/100

108
Q

How does coeliac classically present?

A
  • Diarrhoea/steatorrhoea
  • Anaemic
  • Faltering growth
  • Abdominal distention
  • Arthralgia
  • Buttock wasting
  • General irritability/miserable
109
Q

What are risk factors for developing coeliac disease?

A
  • Type I diabetes
  • Atuoimmune thyroid disease
  • Down syndrome
  • FH
110
Q

What skin manifestation can sometimes be seen with coeliac disease

A

Dermatitis herpatiformis

111
Q

What genetic markers are associated with coeliac disease?

A

HLA-DQ3/DQ8

112
Q

What investigations would you perform if you thought a child had coeliac disease?

A

Bloods

  • Anti-endomysial antibodies (EMA)
  • IgA Anti-TTG (IgA-tTG)
  • Total IgA - if deficient -> IgG anti-gliadin

If bloods positive -> Endoscopy and duodenal biopsy

113
Q

What would you see endoscopically in coeliac disease?

A
  • Scalloping
  • Paucity of the folds
  • Mosaic pattern of the mucosa
  • Prominent submucosal blood vessels
114
Q

Histologically, what would indicate the presence of coeliac disease?

A

Use Marsh criteria to stage;

  • Villous atrophy
  • Crypt cell hyperplasia
  • Lymphocyte infiltration
115
Q

What is important to tell the patient when investigating for coeliac disease?

A

Keep eating moderate gluten diet

116
Q

How would you manage a child diagnosed with coeliac?

A
  • Gluten free diet
  • Consider pneumococcal vaccine
  • Consult dietician
117
Q

What is an important complication to be aware of in coeliac disease?

A

Small bowel lymphoma

118
Q

What other causes of malabsorption can occur in children besides coeliac disease?

A
  • CF
  • Post-enteritis enteropathy
  • Giardia
  • Rotavirus
  • Bacterial overgrowth
  • Short bowel syndrome
119
Q

What parasites can cause gastro-enteritis?

A
  • Giardia
  • Amoeba (Amoebiasis)
120
Q

What is toddler’s diarrhoea?

A

Chronic, non-specific diarrhoea of varying consistency and explosiveness. Can sometimes have undigested food in it

Thought to be due to delay in maturation of intestinal motility

Most children grow out of it by age 5

121
Q

What is defined as chronic constipation?

A

Infrequent passage of dry, hardened faeces often accompanied by straining and pain

122
Q

What is regarded as normal for passage of stool in children?

A
  • Young - 4/day
  • As they get older - down to 2 per day
  • Can be as few as 1 per week
123
Q

What can cause constipation?

A

Often unclear and multifactorial, but can include;

  • Poor diet - dehydration, Excessive milk, Low fibre
  • Intercurrent illness
  • Medication
  • Family history
  • Psychological (secondary) - Potty training/school toilet, stress
  • Organic - hirschsprungs disease, hypothyroid, hypercalcaemia
124
Q

What would you find on examination in a constipated child?

A

Palpable mass in well looking child

ONLY PAEDIATRIC SPECIALIST SHOULD PERFORM RECTAL EXAMINATION

125
Q

What would constipation and failure to pass meconium within the first 24 hours suggest?

A

Hirschprung’s disease

126
Q

What can cause faltering growth and constipation in a child?

A
  • Hypothyroidism
  • Coeliac disease
  • Poor feeding
  • Neglect
  • Other causes
127
Q

What would gross abdominal distention with constipation indicate?

A
  • Hirschprungs disease
  • Other forms of gastrointestinal dysmotility
128
Q

What would constiaption and abnormal lower limb deformity/neurology suggest as a cause of constipation?

A

Lumbosacral pathology

129
Q

What would constipation with a sacral dimple above the natal cleft suggest?

A

Spina bifida

130
Q

What would constipation with abnormal appearence/patency of the anus?

A

Abnormal anorectal anatomy

131
Q

What would constipation iwth perianal bruising/multiple fissuers suggest?

A

Sexual abuse

132
Q

What would consitpation with perianal fistulae/abscesses suggest?

A

Perianal Crohn’s disease

133
Q

What happens physiologically in long-standing constipation?

A

Rectum becomes overdistended, resulting in a loss in feeling the need to defecate. This can lead to dysfunction of the internal sphincter when the rectum contracts around the packed out contents -> Overflow incontinence

134
Q

How does constipation usually present?

A
  • Poor appetite
  • Irritable
  • Lack of energy
  • Distended abdomen
  • Witholding/straining
135
Q

How would you manage a child with constipation?

A

Short term

  • Laxatives

Long term

  • Diet
    • Incerase fibre, veg, fluids, fruit
    • Decrease milk
  • Behavioural/Psychological training
136
Q

What are the different types of laxatives that can be used for constipation?

A
  • Osmotic laxatives (lactulose)
  • Stimulant laxatives (senna, picolax)
  • Isotonic laxatives (movicol) - stool softeners
137
Q

What is faecal impaction?

A

Faeces gets stuck in the bowel

Faeces builds up, stretches rectum, and they lose the ability to sense faeces in the rectum -> faeces from above impaction leaks round the side -> soiling

138
Q

In treating faecal impaction, how should you manage a child once they have been disimpacted?

A

Maintenance with stool softeners

139
Q

If a child was constipated and had palpable faeces in their abdomen, how would you intially manage them?

A

Movicol for 2 weeks

140
Q

If you were treating a child who was faecally impacted with movicol and there had been no spontaneous passage of stool, how would you proceed with their mangement?

A

Stimulant +/- osmotic laxatives

141
Q

If you were treating a child who was faecally impacted and was on all 3 types of laxatives with no spontaneous stool produced, how would you manage?

A

Enema or manual evacuation un GA

142
Q

What is cow’s milk protein allergy?

A

Non-IgE mediated response to cow’s milk protein

143
Q

How does cow’s milk protein allergy usually present?

A
  • Colicky symptoms
  • Loose stool +/- musus/blood
  • Faltering growth
  • Vomiting
144
Q

How would you test for cow’s milk protein allergy?

A

Remove milk from diet for 4 weeks - no other test

145
Q

Once you had determined a child had cow’s milk protein allergy, how would you proceed?

A
  • Remove all milk and wait until 1 year
  • Re-introduce milk using milk ladder
  1. Hydrolysed milk/amino acid feeds
  2. Cooked milk
  3. Cheese/yoghurts
  4. Milk
  • May need thickeners/acid suppression
146
Q

What are the approximate energy demands of a child while they are growing?

A

95-110 kcal/kg/day

147
Q

How much protein do children need per day?

A

Protein 1.5-2g/kg/day protein

148
Q

What vitamin are children at risk of becoming deficient in (esp. in scotland)?

A

Vitamin D

149
Q

What are the benefits of breastfeeding?

A
  • Suckling/bonding
  • ‘Perfect’ nutrition for 6 months for most infants
  • Tailor-made passive immunity (NB HIV)
  • ­Development of infant’s active immunity
  • ­Development of infant’s gut mucosa
  • Reduced infection
  • Almost no contaminants
  • Antigen load minimal
  • Cheap
  • ? Breast cancer
150
Q

How can children with Crohn’s disease present?

A
  • Faltering growth/failure
  • Abdominal pain
  • Diarrhoea +/- blood and mucus
  • Weight loss
  • Fever/lethargy
  • Pubertal delay
  • Extra-intestinal manifestations
151
Q

What are extra-intestinal manifestations of Crohn’s disease?

A
  • Oral lesions/perianal skin tags
  • Arthralgia
  • Erythema nodosum
  • Uveitis
152
Q

How does Crohn’s differ from UC?

A
  • More weight loss and growth failure
  • Less diarrhoea and rectal bleeding
  • Masses can sometimes be palpated in the abdomen
153
Q

How does UC differ from Crohn’s clinically?

A
  • More diarrhoea and rectal bleeding
  • Less weight loss and growth failure
154
Q

What similarities do Crohn’s and UC display clinically?

A
  • Abdominal pain
  • Arthritis
  • Fever
155
Q

What is Crohn’s disease?

A

Inflammatory bowel disease characterised by patchy segmental transmural chronic granulomatous inflammation which is associated with fissures, neuromuscular hypertrophy, strictures and fistula.

156
Q

What is Ulcerative colitis?

A

Chronic remitting and relapsing inflammatory disease of the large intestine associated with the passage of blood, mucus and pus.

_Only affects colon_ - usually starts distally and works proximally

157
Q

Where does Crohn’s most commonly affect in the GI tract?

A

Distal ileum/proximal colon

158
Q

If you suspected inflammatory bowel disease, what investigations would you perform?

A

Bloods and biochemistry

  • Full blood count - Anaemia, Thrombocytosis
  • CRP & ESR - raised
  • Low Albumin

Specific tests

  • Stool calprotectin - raised - important marker

Imaging

  • MRI - Barium meal and follow-through (younger kids)

Endoscopy/Colonoscopy

159
Q

How would you manage a child with IBD?

A

Medical

  • Anti-inflammatory
  • Immuno-suppressive - Steroids
  • Biologicals (Infliximab)

Nutritional

  • Immune modulation
  • Nutritional supplementation - used more in children than adults

Modulen IBD - 6 weeks - 75-80% response rate

160
Q

What histological findings would indicate crohn’s disease?

A

Non-caseating epithelioid granulomata

161
Q

What are the complications of IBD?

A
  • Inflammation
  • Ulcers
  • Abscess
  • Fistulas
162
Q

How is remission induced in Crohn’s?

A

Nutritional therapy - replaced with modular feeds

If that fails - steroids

163
Q

What is Hirschprungs Disease?

A

Abscence of myenteric and submucosal plexuses of parts of the large bowel -> narrow, contracted segment of large bowel

75% of cases - confined to the rectosigmoid

10% - entire colon involved

164
Q

How can Hirschprungs Disease present in the neonatal period?

A
  • Failure to pass meconium
  • Intestinal obstruction
    • Abdominal distention
    • Bilious Vomiting
  • Flatus
165
Q

How can hirschprungs disease present in childhood?

A
  • Chronic constipation
  • Abdominal distention
  • Growth Failure

Paediatrics (27 decks)

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