Gastrointestinal Flashcards
What is the duration for constipation to be chronic?
Over 8 weeks
Encoperesis - what is it?
Soiling
Usually due to overflow diarrhoea
Red flag symptoms for constipation (+ conditions this indicates)
Failure to pass meconium = CF, Hirschprungs
FTT = CF, coeliac, hypothyroidism
Distension = Hirschsprungs
Sacral dimple above natal cleft = spina bifida
Perianal fistulae/ abscesses = Crohns
Constipation medical management
Disimpaction = macrogol laxatives
Escalating dose for 1-2 weeks
Add stimulant laxative after 2 weeks
Maintenance = lower dose macrogol
Gastroenteritis organisms, S+S
Usually rotavirus (infant) or noravirus (all kids), campylobacter (severe abdominal pain), shigella + salmonella (blood + mucus in stool)
Sudden onset
Fever Abdo pain Vomiting Shock
Gastroenteritis - investigations
Bloods, ABG if in shock
Stool sample if blood/ mucus in stools
Gastroenteritis management
Oral rehydration solution or fluid therapy 20mls per kg of NaCl = for bolus
UNLESS DKA, head injury, congenital heart problems (give 10mls per kg)
Gastroenteritis complications
Haemolytic uraemic syndrome = complication of E coli
IV fluids can cause decreased sodium concentration = cerebral oedema + seizures
Other causes of diarrhoea
Coeliac, IBS, IBD + toddlers diarrhoea
GORD - how common, when does it present, what causes it
Disease = only if symptomatic
40% of infants experience reflux
First 2 weeks of life
Due to incompetence of sphincter
Better with age due to solid food, time spent upright + strengthening sphincter
GORD S+S
Presenting as ‘vomiting’ - non-forceful regurg
Feeding difficulties - distress after feeding
Irritability
Resistance + arching with feeding
Usually put on weight gain fine - can get FTT
Apnoeas + cough + stridor
GORD complications
Oesophagitis = haematemesis, anaemia
Resp symptoms = cough, wheeze, aspiration pneumonia - can be life threatening FTT
Sandifers syndrome = associated with dystonic neck movements
GORD management
Conservative: avoid overfeeding, sit up (cot slanted, burping after)
Milk thickeners (for bottle fed) Gaviscon (for breast fed)
H2/ PPIs - can increase risk of NEC in preterms
Surgical - for kids with neuro problems
GORD investigations
Diagnosis is clinical
Potential investigations (for older kids) :
FBC - check for anaemia
24hr oesophageal pH study
Endoscopy - if oesophagitis suspected
Mamometry - assesses oesophageal motility + sphincter function
Barium meal
Vomiting in distal v proximal obstruction
Proximal = more bile stained vomit + more forceful
Distal = more abdo distension
Causes of vomiting
Feeding errors - faulty technique, dietary restrictions
Infections - GI, appendicitis, paraenteral
Obstruction
Raised ICP - meningitis, encephalitis, space occupying lesion
12 vomiting red flags (+ conditions they are associated with)
Bile stained = intestinal obstruction (duodenal atresia)
Haematemesis = oesophagitis, ulcers
Projectile = pyloric stenosis
Vomiting after coughing = whooping cough
Abdo tenderness = surgical abdo
Abdo distension = intestinal obstruction, inguinal hernia
Hepatosplenomegaly = liver disease
Blood in stool = intusseception, gastroenteritis
Severe dehydration = systemic infection, DKA
Bulging fontanelle/ seizures = raised ICP
FTT = reflux, coeliac
LOC = meningitis, infection
Causes of acute abdo pain in newborns
Intestinal obstruction (Hirschprungs, volvulus, pyloric stenosis)
Hernia
Necrotising enterocolitis
Reflux
Vomiting - medical reasons
Gastroenteritis, reflux, infection, intolerance, ulceration, migraine
Vomiting - surgical reasons
Intestinal obstruction, pyloric stenosis, duodenal atresia, intusseception, malrotation, volvulus, Hirschprungs
Causes of acute abdo pain in infants (<2)
Constipation Hernia Volvulus Intussusception Colic UTI
Causes of acute abdo pain in children 2-18 y/o
Appendicitis DKA Henoch-Schnolein Purpura UTI Mesenteric adenitis Gastritis Constipation Intestinal obstruction
Causes of acute abdo pain in adolescents
Dysmenorrhoea PID Ovarian torsion Testicular torsion Pregnancy
7 abdo pain red flags (+ conditions this indicates)
Bloody stool = UC, necrotising entercolitis, constipation, intussesception
Haematemesis = ulcers, gastritis
Bilious emesis = bowel obstruction
Jaundice = hepatic/ biliary obstruction
Joint pain = IBD, HSP
Skin lesions = IBD, HSP, liver disease
SOB = pneumonia
3 recurrent abdo pain causes
Pain lasting more than 3 months
Usually due to IBS, abdo migraine or functional dyspepsia
IBS: explosive stools, bloating, feeling of incomplete defecation, constipation, abdo pain
Abdo migraine = headaches + abdo pain
Functional dyspepsia = bloating, early satiety, reflux
Functional dyspepsia management (+ H pylori treatment)
H pylori = amoxicillin + metronidazole
PPIs
Appendicitis - S+S, investigations + management
Vomiting
McBurnys point - RIF pain + guarding
Rovsing’s sign - pressure in L side gives pain in R side
Faecalith = preschool children = blocks appendix
USS
Appendicectomy
Coeliac disease - pathology, presentation, investigations, management, complications
Gluten provokes damaging response in proximal small intestinal mucosa
Villi become shorter and absent, leaving flat mucosa
HLA-DQ2/8
Presents as malabsorption at 8-24 months
Loose stools, FTT, abdominal distension, short stature, anaemia
Serology testing - IgA tissue transglutaminase antibodies
Endoscopy + biopsy = villous atrophy, crypt hypertrophy
Associated w/ Downs, Turners + T1DM
Gluten free diet
Complications: anaemia, osteoporosis, malignancy
Undescended testicles - types, management
Normally descend on 36th week
Retractile = testis can be manipulated into the scrotum but then retract
Palpable = testis can be palpated in groin
Impalpable = no testis felt
Review at 6-8 weeks
Review at 3 months - If still undescended - do orchidopexy
Inguinal hernia - cause, S+S, management
Usually indirect - due to patent processus vaginalis
Common in premature babies
S+S: intermittent swelling in groin, firm and tender
Opioid analgesia + compression
Surgery after 24-48 hours
Intussusception pathology + causes
Invagination of proximal bowel into distal segment
Commonly = ileum passing into caecum
Causes: change in diet, viral infection
Causing hypertrophy of Peyer’s patches - causes obstruction + ischaemia
Intussusception S+S + who does it commonly affect?
Colicky paroxysmal pain
Pale, draws legs up
Refusing feeds
Vomiting - may be bile stained
Redcurrent jelly stool
Commonl boys, 5-10 months
Intussusception investigations, management + complications
Investigations: examination = sausage shaped mass
AXR (bowel dilation), then USS showing target sign
NBM, NGT, rectal air insufflation/ enema
DON’T DO AIR ENEMA if there is a prolonged hx (>24hrs) or already showing signs of peritonitis = may cause perforation
Complication: stretching + constriction of mesentery causing venous obstruction = leads to bowel perforation, peritonitis + gut necrosis - on AXR may have football sign
Causes of unconjugated jaundice
Breast milk jaundice Infection (UTI)
Haemolytic anaemia
Hypothyroidism
High GI obstruction
Crigler-Najjar obstruction
Causes of conjugated jaundice
Bile duct obstruction
Neonatal hepatitis (Hep A)
S+S jaundice
Pale stools, dark urine, bleeding, FTT
Mesenteric adenitis - what is it, differentiation with appendicitis
Inflamed lymph glands in abdo - cause abdo pain
Usually due to viral infection
High fever (whereas appendicitis is low grade fever)
Accompanied by URTI with cervical lymphadenopathy
Resolves within 48 hours
Pyloric stenosis - what is it, onset, S+S, management
Hypertrophy of muscle causing gastric outlet obstruction
Presents between 2-7 weeks
S+S: vomiting, increasing in forcefulness
Dehydration, FTT Visible peristalsis
Palpable abdo mass in RUQ
Hypocholoraemic metabolic alkalosis - low sodium + potassium
Management: pyloromyotomy
Testicular torsion - RF, S+S, management
RF: high insertion of tunica vaginalis = bell clapper testis with horizontal lie
S+S: sudden onset severe pain, often comes on during sport, N+V, acute swelling
Surgery within 12 hours
Biliary atresia - what is it, S+S, management, complications
Destruction of biliary tree + ducts
S+S: FTT, jaundice (prolonged), pale stools + dark urine, hepatosplenomegaly
Surgically bypass fibrotic ducts (hepatoportoenterostomy = Kasai procedure)
Post op complications: cholangitis, malabsorption of fats + fat soluble vitamins, portal HTN
Duodenal atresia - cause, S+S, investigations
Double bubble on XR
Bilious vomiting
Congenital
Hepatitis S+S
N+V Abdo pain Lethargy Jaundice Large tender liver Splenomegaly Increased liver transaminases
Hep A - cause, S+S, diagnosis, management
RNA virus spread by faecal oral route
Common cause of childhood jaundice
Prodrome (week 1) then jaundice for week 2-3
Raised bilirubin, AST + ALT
Diagnose with IgM antibody to virus
Give prophylaxis with immunoglobulin to close contacts or vaccinate within 2 weeks
Hep B - cause, transmission from mother to baby
DNA virus - usually passed on from mothers
Asymptomatic carriers if infected perinatally
IgM ab (anti-HBc) are +ve in acute infection +ve HBsAg = ongoing infection
Hep C - transmission from mother to baby
Vertical transmission - causes children to be carriers with progression to cirrhosis
Crohns - pathology, S+S, management
Transmural inflammatory disease with non-caseating epitheloid cell granulomata
S+S: abdo pain, diarrhoea, rectal bleeding, growth failure, raised crp polymeric diet for 6-8 weeks, immunosuppressant meds
UC - pathology, S+S, management
Inflammatory + ulcerating disease - mucosal inflammation, crypt damage, ulceration
S+S: rectal bleeding, diarrhoea, colicky pain, weight loss, growth failure
Treat with aminosalicylates, steroids + immunosuppression
Volvulus - causes, S+S, management
Malrotation = failure of gut to rotate + return to abdo
Causes obstruction with bilious vomiting + ischaemia manage surgically
How much milk should babies have in a day?
150ml/kg/ day
RF for GORD
More common in floppy babies eg Downs/ neuro problems (CP)
Preterm Hypotonic
Males
Cows milk
Obesity
What are the downsides of breastfeeding?
Increased frequency of feeds
Less vitamin D - may need a supplement
What is the most common cause of PR bleeding in neonates?
Swallowing blood from CS or placental abruption
Cows milk protein allergy - causes pink frothy stools
S+S cows milk protein allergy
D +V Abdo pain
Blood in stools
Hives/ eczema
Wheezing, irritability, facial swelling FTT
What is oesophageal atresia + tracheosophageal fistula + RF?
Atresia = doesn’t connect with stomach, ends in pouch
Fistula = connects with trachea
RF: polyhydraminos
What is Crigler Najjar syndrome?
Causes non-haemolytic jaundice causing high unconjugated bilirubin in neonates
LFTs normal
Autosomal recessive
Needs liver transplant
What is Gilbert’s syndrome?
Common cause of unconjugated high bilirubin
Jaundice precipitated by illness, stress etc
Prolonged constipation (for years), distended bowel, faecal loading (on AXR), failure to pass meconium for a few days - what is it?
Hirschprungs
What is Hirschprungs?
Absence of myenteric + submucosal ganglia cells in rectum
Due to failure of neural crest cells to migrate in week 8-12
Results in aganglionic section that is unable to relax
RF for Hirschprungs
Boys more common
Downs + other inherited conditions
S+S of Hirschprungs
Abdo distension, vomiting, constipation, delayed meconium, FTT, poor nutrition
Investigations + management of Hirschprungs
AXR - faecal loading + dilated bowel
Barium enema + biopsy
Surgery = removal of segment with end-end anastomosis OR removal of aganglionic segment + colostomy to allow decompression of dilated bowel
Complications of Hirschprungs
Soiling
Enterocolitis - can become life threatening - stool sample to be sent to check for viral causes
Incontinence
Constipation
Stricture
Obstruction
What are Peyer’s patches?
Lymph nodes in bowel
Commonly involved in intusseception in young children (due to recent viral illness causing inflammation of Peyer’s patches)
What defects are tracheo-oesophageal fistulas associated with?
horseshoe kidney, AV septal defects + imperforate anus, also oesophageal atresia – common in genetic disorders
How does a tracheo-oesophageal fistula present?
choking + coughing during for during feeds, abdo distension + LRTIs
What is VACTERL?
Verterbral anomalies
Anorectal anomalies
Cardiac anomalies
TOF + oesophageal atresia
Renal tract abnormalities
limb anomalies
What is Meckel’s diverticulum, how does it present + what is the rule of 2s? What scan is diagnostic?
Vitelline duct remnant
Rule of 2s – 2% of people, 2cm long, 2ft from end of gut
Can cause rectal bleeding, discharge from umbilicus + bowel obstruction/ intussecption in older children.
Presents like appendicitis.
T99 scan is diagnostic
When should you repair umbilical hernias by?
4-5 years
What is a torted hydatid?
testicular pain, pea sized blue swelling
What is a hydrocele?
Fluid in the scrotum leading to swelling
What is phimosis?
Tight foreskin
What is epididymitis?
inflammation causing pain, dysuria, frequency + scrotal pain, swelling – STI related
What is epispadias?
urethral meatus on dorsal aspect
What is priapism?
Painful + prolonged erection
What is cryptorchidism?
Undescended testes - common in preterms
Should descend by 6 months - if not, fix by 1 year
What is the coffee bean sign?
Large bowel obstruction that folds itself double
