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Gastrointestinal Flashcards

1
Q

What is the surgical sieve?

A

A mnemonic used to think of differential diagnoses of problems.

VITAMIN D

Vascular
Infective / inflammatory
Trauma
Autoimmune
Metabolic
Iatrogenic / idiopathic
Neoplastic
Developmental
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2
Q

Differential diagnosis of vomiting?

A

V: vascular - intracranial haemorrhage

I: infection - UTI, gastroenteritis, meningitis

T: trauma

A: autoimmune - IBD, Coeliac

M: metabolic - GORD, pyloric stenosis, intussusception

I: iatrogenic / idiopathic - overfeeding

N: neoplasia

D: developmental - malrotation, Hirschprung’s

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3
Q

If a child projectile vomits, what are you immediately thinking of?

A

Pyloric stenosis

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4
Q

What is pyloric stenosis? What’s the pathogenesis?

A

Hypertrophy and hyperplasia of the pylorus (sphincter) and the antrum of the stomach

Causing narrowing of exit from stomach to duodenum

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5
Q

At what age does pyloric stenosis usually present?

A

3-8 weeks

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6
Q

Presentation of patients with pyloric stenosis?

A

Vomiting occurring minutes after feeds which worsens until it is projectile (a good few metres)

Non-bilious vomit

Constipation, few stools

Do not appear too ill, but are hungry and grumpy

Dehydration

Poor weight gain

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7
Q

On examination what would you find on a patient with pyloric stenosis?

A

Olive shaped mass which is the hypertrophic pylorus. Felt in RUQ or epigastrium

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8
Q

Investigation of suspected pyloric stenosis?

A

Bloods: the usual, U+E to look for signs of dehydration, electrolyte imbalance

USS

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9
Q

What would U+E and blood gas results show in pyloric stenosis?

A

U+E:
hypernatraemia (due to dehydration)
hypokalaemia (due to vomiting)
High creatinine + urea + albumin (due to dehydration)

Blood gas:
You’d see metabolic alkalosis due to loss of HCl when vomiting

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10
Q

Management of pyloric stenosis?

A

Stabilise before surgery: rehydrate, correct electrolyte imbalance

Surgery: open up pylorus pyloromyotomy

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11
Q

What is Hirschprung’s disease? (simply)

A

Simply put, it’s an absence of nerve supply to the rectum and sometimes the end of the colon

This leads to the rectum becoming stiff and unable to do peristalsis, so it becomes an obstruction and stool can’t move through

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12
Q

What’s the pathophysiology of Hirschprung’s disease?

A

Absence of parasympathetic ganglion cells in the myenteric and submucosal plexus of the rectum (and possibly into the colon)

The nerve supply never develops during gestation

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13
Q

Is it parasympathetic or sympathetic nervous system that’s lost in Hirschprung’s disease? What happens as a result?

A

Parasympathetic supply is lost.

Parasympathetic system initiates digestion, so peristalsis of gut. In Hirschprung’s you have loss of peristalsis

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14
Q

Presentation of Hirschprung’s disease in neonates?

A

Delayed (after 48 hrs) or no passage of meconium. Sometimes meconium passage is normal though

Vomiting

Distended abdomen

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15
Q

Presentation of Hirschprung’s disease in infants and children?

A

Chronic constipation resistant to usual treatments

Early satiety, abdominal discomfort, poor nutrition and weight gain

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16
Q

Investigation of suspected Hirschprung’s disease?

A

Bloods

Abdominal X-ray: you’d see obstruction, a dilated lower bowel

Anorectal manometry

Rectal biopsy (diagnostic)

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17
Q

What on earth is anorectal manometry?!

A

Detects the pressures of the anal sphincter muscles

Sensation in the rectum

Neural reflexes that are needed for normal bowel movements.

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18
Q

Patients with Hirschprung’s disease are at higher risk of developing what? How would you manage in that situation?

A

Enterocolitis, infection of intestinal tract

Broad spectrum antibiotics, fluid rehydration

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19
Q

List some broad spectrum antibiotics?

A

Amoxicillin
Streptomycin
Chloramphenicol
Levofloxacin

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20
Q

Non-surgical management of Hirschprung’s disease?

A

IV rehydration

Cessation of oral feeding

Decompress obstruction: NG tube, DRE, saline enema

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21
Q

Surgical management of Hirschprung’s disease?

A

Pull-through: remove aganglionic part of bowel and attach two ends together

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22
Q

What does atresia mean? List some types.

A

When an orifice or passage is closed off

Oesophageal atresia: when the oesophagus is blind ended and doesn’t connect to the rest of the oesophagus and into stomach. Like two sausages in a line.

Biliary atresia: atresia in ducts of biliary tree

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23
Q

What other structural abnormality is often seen with oesophageal atresia?

A

Tracheo-oesophageal fistula

The second half of the oesophagus is looking for somewhere to attach to so it attaches to the trachea.

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24
Q

What is intesussception?

A

Invagination of a proximal bit of bowel into a distal bit, ‘telescoping’

Causing obstruction

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25
Which part of the bowel is most commonly involved in intesussception?
The ileum goes into the caecum through the ileocaecal valve
26
Presentation of intusussception? Common age range?
3 months to 2 years Paroxysmal episodes of severe colicky pain and pallor, they draw up their legs in pain Refusing feeds Vomiting, may be bilious if below sphincter of oddi Redcurrant jelly stool, blood + mucus Abdominal distension and shock
27
What's the cause of intusussception?
No known cause Thought that there could be a link with viral infection
28
Why does intusussception lead to shock? What type of shock?
Hypovolaemic shock Because fluid pools in the gut? So less in circulation? Not too sure
29
Investigations of suspected intusussception?
Bloods X-ray: distended small bowel, can sometimes see intusussception USS
30
Management of suspected intusussception?
Fluid resuscitation if in shock Air enema with USS guidance: blow air up through the rectum If this fails surgery to reduce
31
Describe the pathophysiology of malrotation?
During fetal development, the bowel comes out of the abdomen and then folds back in a particular way. In malrotation, the bowel folds back in abnormally and is not fixed correctly. Sometimes this causes no problems Sometimes it leads to increased risk of obstruction and volvulus
32
Why does malrotation lead to obstruction?
Bowel is not fixed so more likely to twist There are 'Ladd bands' which cross the duodenum which contribute to obstruction
33
Presentation of malrotation?
Bilious vomiting Abdominal pain, paroxysmal, drawing up legs Not passing faeces, or very little If bowel blood supply is lost, necrosis leading to peritonitis: abdo distention, toxic Dehydration
34
What is bilious vomiting, what should you immediately think of?
Green vomit Malrotation, investigate urgently
35
Investigations of suspected malrotation?
Urgent upper GI tract contrast study | Also bloods etc.
36
What age does malrotation usually present?
Often in first few months of life But can be any time
37
What's the most common type of malrotation?
Duodenojejunal flexure is further right than it should be Caecum is high in RUQ
38
Management of malrotation?
Surgery to fix bowel into (pretty) normal place If you think blood supply could be compromised, urgent laparotomy
39
Draw out a picture of volvulus and malrotation?
https://www.google.co.uk/search?q=volvulus&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjLmcafssbWAhXBD8AKHSbyDaYQ_AUICigB&biw=1536&bih=723#imgrc=mj6fGKmXpzkKiM:
40
What is volvulus?
When the bowel twists round itself and the mesentery causing a blockage
41
What is toxic megacolon? What's the usual cause?
When the colon becomes very dilated and can lead to shock Usually IBD, most often ulcerative colitis
42
What's the pathophysiology of toxic megacolon?
Inflammation and damage to the colon wall caused by toxins Breakdown of mucosal layer, destruction of the nerve supply and damage to colonic musculature Leads to a pretty much paralysed colon Pressure builds up in the colon due to faecal stasis This can lead to sepsis and perforation
43
Clinical features of suspected toxic megacolon?
Abdo pain, tenderness Bloating Fever Shock
44
Management of toxic megacolon?
Decompress with suction Colectomy
45
What is coeliac disease?
Dietary gluten causes autoimmune reaction which causes inflammation of the small bowel
46
Which part of the gluten are coeliac patients intolerant to?
Peptide, called alpha-gliadin
47
Presentation of coeliac disease? What age?
Any age, but commonly infancy when weaning and 5th decade Can be non specific: - malaise - fatigue Small bowel disease: - diarrhoea, Steatorrhoea - abdominal pain - anorexia, weight loss Malabsorption: - anaemia - nutritional deficiency
48
What deficiencies are commonly seen in coeliac disease? | Why?
Folate Vitamin B12 Iron deficiency The body is not able to absorb these very well via small bowel
49
Investigations for coeliac disease?
Serum antibodies Anti-gliadin Anti-endomysial Tissue transglutaminase
50
Differential diagnosis of diarrhoea?
Gastroenteritis Systemic infection: UTI, pneumonia, meningitis IBD Intolerance: lactose, milk protein Malabsorption: coeliac, CF Surgical problem Encopresis: constipation with overflow Hyperthyroidism Toddler's diarrhoea Psychological (IBS)
51
Describe pathophysiology of encopresis?
When faeces stay in the bowel for a long time, water is drawn out of them making them hard. The hard faeces stretches and weakens bowel wall Liquid stool from higher up leaks around it and out. Patient is unaware they're passing stool
52
Which age group are susceptible to encopresis?
up to age 4
53
How do patients with encopresis present?
``` Constipation Leaking of stool Explosive diarrhoea Nausea + vomiting Dizziness Tachycardia ```
54
Management of encopresis?
Disimpaction regime (laxatives) Or use a clean prep (like used for colonoscopy) during a hospital stay Advise on diet (more fibre, fruit and veg)
55
When do children usually grow out of Toddler's diarrhoea?
By age 4
56
List some causes of proteinuria in children?
UTI Nephrotic syndrome Renal dysplasia and reflux Nephritis
57
What is nephrotic syndrome? What's the diagnostic criteria (in children)?
A set of symptoms/signs (see below) with different causes Diagnostic criteria: - proteinuria - low serum albumin - clinical evidence of peripheral oedema
58
List some causes of nephrotic syndrome?
Congenital nephrotic syndrome ``` Idiopathic Glomerulosclerosis Glomerulonephritis SLE Diabetes ```
59
Management of nephrotic syndrome?
Steroids! Prednisolone Fluid restriction, low salt diet Diuretics Others: cyclophosphamide, cyclosporin
60
What's the prognosis of nephrotic syndrome?
1/3 resolve 1/3 have infrequent relapses 1/3 have frequent relapses

Child Health (17 decks)

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