Gastrointestinal Flashcards
What is physiological, pathological and prolonged jaundice?
Phy: >24hours, Peaks 3-4days, Resolves after 14days
Path: First 24hours
Pro: >14 days at term or >21 days premature
What are the causes of physiological, prolonged and pathological jaundice?
PHYSIOLOGICAL: Bilirubin produced by inc erythrocyte breakdown of fetal Hb replaced by adult Hb Immaturity of bilirubin conjugation system Prematurity Bruising Sepsis Haemolytic disease Infection Breast milk PATHOLOGICAL: Rhesus & ABO Haemolytic disease Red cell enzyme defect (G6PD) Sepsis Hereditary spherocytosis Sickle cell anaemia PROLONGED: biliary atresia hypothyroidism galactosaemia UTI breast milk jaundice congenital infections (TORCH)
What are the investigations for neonatal jaundice?
Serum Bilirubin: Tx if >260
PROLONGED: Coomb’s test & Group- Incompatibility, consider haemolytic disease of the newborn, urine culture & MCS, metabolic screen, FBC, conjugated bilirubin
?Infection: TORCH screen, blood culture
Bloods: FBC, blood film, U&E, TFTs, LFT, G6PD (ethnicity)
What are the signs & symptoms of neonatal jaundice?
Cephalocaudal progression
Yellowed skin +/- sclera
Kernicterus: Unconjugated bilirubin crossing blood-brain barrier causing permenant neuronal damage
Bilirubin encephalopathy: Irritability, high pitched cry, inc muscle tone, (retrocollis & opisthotonus), abnormal moro reflex
How is physiological and pathological jaundice managed?
Serum B <260: Conservative
Serum B >260: Phototherapy (cover eyes)- repeat bilirubin 4-6hrs later
Hydrate (breast milk)
Pathological: Regardless of bilirubin levels phototherapy
Consider: Exchange transfusion
How is prolonged jaundice treated?
ANY BABY JAUNDICE >14d= Conjugated Bilirubin
Conjugated bilirubin <25 : Check for metabolic disease
Conjugated bilirubin >25: Check for biliary duct disease (biliary atresia confirmed= abdo USS- requires surgery/liver transplant)
What does the TORCH screen assess for? What are the associated features of these infections?
Toxoplasmosis Rubella Cytomegalovirus: Associated hepatomegaly Herpes Simplex HIV Associated features of ALL: Low birth weight, prematurity, jaundice, microcephaly, seizures, anaemia, FTT, encephalitis
What are the red flag signs when taking a GI history and what do they represent?
Vomiting: Onset after 6m or persisting beyond 1yo
Projectile vomiting: Pyloric Stenosis
Bile stained vomit: Intestinal obstruction
Abdo distension/tender/mass: Obstruction
Haematemesis
Bulging fontanelle: Raised ICP
Chronic diarrhoea: CMPA
Bloody stools: CMPA, bacterial GE
Rapid inc head circumference w/headache: Raised ICP
What is normal stool passage in children?
<1w: 4/day
1yr: 2/day
>4yr: 3/day-3/week
What are the causes of constipation in a child?
Idiopathic: Diet, exercise, poor motility, poor activity Hirschprungs Anal disease Hypersensitivity Obstruction Thyroid Neuro disease HyperCa Dehydration Drugs Sexual abuse
What are the red flag signs in a child with constipation?
Onset in first few weeks of life Delay in passing mec Abdo distension w/vomiting Fhx Hirschprungs Ribbon stool pattern Leg weakness/ motor delay Abnormal anal appearance: Perianal fistulae, fissures, abscess Abuse Cows milk protein allergy Failure to thrive Abnormal lumbosacral & gluteal regions
How is constipation managed?
Not impacted: Dietary, young = lactulose, older= Movicol
Impacted: Disimpaction regime (with Movicol), Glycerol suppository, phosphate enema, manual evac
Behavioural: Stool chart, toilet time, star chart
What are the causes of GE?
Most viral: ROTAVIRUS, Norovirus, Adenovirus
Bacterial: Campylobacter, E.Coli, Shigella, Salmonella
Parasitic: Giardia, Cryptosporidium
What are the signs & symptoms of GE?
Sudden onset watery diarrhoea vomiting More common in bottle fed babies Cramping Fever Dehydration Electrolyte imbalance URTI w/rotavirus Bacterial: Bloody stools & tenesmus, dysentry (Blood & mucous in diarrhoea)
What are the complications of GE?
Bacteraemia Secondary infection Reiter's syndrome HUS Guillain-Barre Reactive arthropathy Haemorrhagic colitis
How is GE investigated?
Stool microscopy
Blood cultures
Stool C. Diff toxin
Sigmoidoscopy
How is GE treated?
Rehydrate: ORS solution (200ml >5yr after every loose stool)
Campylobacter: Erythromycin
Avoid contact for 48hours
Educate parents on sterilising bottles
What are the RFs for GORD in a child?
Prematurity Obesity FHx LOS dysfunction: Hiatus hernia Oesophageal atresia Neurodisability
What is the pathophysiology of GORD?
Transient lower oesophageal sphincter relaxation & effortless passage of gastric content into oesophagus Narrow oesophagus Delayed gastric emptying Liquid diet Low LOS Usually before 8w 90% resolve <1yr
What are the signs & symptoms of GORD in a baby?
Regurgitation Distressed Excessive crying/ crying whilst feeding Hoarseness Chronic cough Wheeze Recurrent pneumonia Apnoea Unexplained feeding difficulties Faltering growth Retrosternal pain Unusual neck posture (Sandifer's syndrome)
What are the red flag signs for GORD?
Projectile vomiting Bilious vomiting Abdo distension Haematemesis Raised ICP
How is GORD investigated?
When diagnosis is uncertain due to poor Tx response pH study: X-ray with pH probe Upper endoscopy Oesophageal biopsy Radioisotope milk scan Barium enema CXR
How is GORD managed?
Position: Nurse head-up & prone
Diet: Thickened milk (Carabel), small frequent feeds, avoid food before sleep
Drugs: Gaviscon, Omeprazole/ Ranitidine, Domperidone
Surgery
What are the causes of vomiting?
Acute: MOST COMMON, infection, food reaction, obstruction, DKA, raised ICP, poisoning
Chronic: PUD, obstruction, GORD, Chronic infection, food allergy, pregnancy, over-feeding
Cyclic: CNS disease, idiopathic, migraine, endocrine, metabolic
How is cyclic and chronic vomiting defined?
Cyclic: Severe, discrete episodes w/pallor, lethargy & abdo pain
Chronic: Low grade, daily, mild illness
How is vomiting investigated?
Bloods: FBC, CRP, U&E, LFTs,
H.Pylori test
Endoscopy
Abdo USS
Would you be worried if a baby hadn’t passed meconium in the first 48hours-why?
YES consider: DIOS: Meconium ileus but in older children CF:Meconium ileus Obstruction GI atresia
How is pyloric stenosis investigated & treated?
Ix: USS >4mm width, >17mm length, pyloric stenosis (olive shaped) mass felt w/feeding test, Blood gas (MA), Bloods: U&E, FBC, LFT, CRP
Tx: Rehydrate: IV 0.45% Saline w/5% Dextrose & 20mmol KCl, Pyloromyotomy
What are the signs & symptoms of pyloric stenosis?
Typically 2-7weeks of age Projectile vomiting non-bile stained Hungry baby Weight loss Metabolic alkalosis w/ hypoChlor, hypoK Usually first born male Constipation
What are the signs & symptoms of malrotation w/volvulus?
Young child
Green bilious vomiting
What is the pathophysiology of malrotation w/volvulus?
Abnormal fixation of s.bowel mesentry making it prone to twisting
How is Malrotation w/volvulus investigated?
Upper GI contrast study
NG tube inject contrast into stomach
Look for emptying
How is Malrotation w/volvulus managed?
Surgical emergency
Risk of bowel infarct
How is bowel obstruction investigated?
AXR to evaluate level of obstruction
Barium swallow/enema for exact level
What are the causes of bloody diarrhoea?
E.Coli Campylobacter Shigella C.Diff Amoeba
What causes a food allergy?
IgE mediated (type 1 hypersensitivity)
What are the most common food allergies?
Cows milk Nuts: Peanuts, tree nuts, sesame Eggs Wheat Soya Kiwi
What are the signs & symptoms of a food allergy?
Diarrhoea +/- mucus/blood Vomiting GORD Abdo pain Eczema Urticaria Asthma Anaphylaxis
How is a food allergy investigated?
RAST/ELISA: Detect IgE
Serum IgE/eosinophils
Skin prick test
What are the signs & symptoms of a cows milk protein allergy?
Colic Oesophagitis Lactose intolerance Constipation Blood/mucus in stools
USE: Hydrolysed formula
What is the difference between a food allergy & a food intolerance?
Intolerance = Adverse reaction to food not immune mediated e.g enzyme deficiency or reaction to food toxins
When are investigations for jaundice not needed?
- Jaundice not apparent in first 24hrs
- Infant clinically well & remains well
- Serum bilirubin below Tx level
- Jaundice resolved by day14/21 in preterm
(e. g breastfeeding causing jaundice)
How would you take a jaundice Hx?
Unsettled Drowsy RF for: Sepsis, PPROM Fix: Haemolytic disease Colour of urine/faeces
What is the Rome criteria?
Criteria for constipation must Have >2:
- <2 defecations/week
- > 1/week of faecal incontinence after child has acquired toilet skills
- Hx of excessive stool retention/retentive posturing
