Gastrointestinal Flashcards
GORD Referral paeds
SAME Day if haematemesis, melaena, dysphagia
Assessment if red flag sx
Refer if Cx
Red flags for paeds GORD
Faltering growth Unexplained distress Unresponsive Unexplained IDA No improvement after 1yr
Cx of paeds GORD
Reccurent aspiratoion pneumonia unexplained apnoea unexplained epileptic like seizure Unexplained upper airway inflam. dental erosion w/neurodisability recurrently acute otitis media
2 Mx of GORD
Reasure: v common, <8wks old, self resolves
R/v only if: projectile, bilestained vomit/haematemesis, >1yr
Non-pharm Mx of GORD
NOT positional while asleep
Bf: assess bf, if issue persists try alginate therapy for 1-2w (stop at intervals to assess)
FF: R/v Feeding Hx, aim for 150-180ml/kg/day, offer thickened formula, alginate therapy
Pharm Mx of paed GORD
4 wk trial of PPI/histamine antagonist if 1+: - unexplained feeding diffuclty - distressed behaviour - faltering growth (also if complaining of heartburn)
PACES of GORD in paeds
Dx: immaturity of foodpipe leads to food coming back up
Is common usually self resolves
BF: assess, alginate
FF: r/v feed Hx, smaller volumes, thickener, alginate
safety net: if green or bloody seek help
Pyloric stenosis
Ix: USS, U+E
IV fluid resus. essential to correct electrolyte imbalance before surg. (1.5x maintenance rate w/5% dextrose+0.45%saline)
Ramstedt pyloromyotomy
(divide down to but not inc. mucosa)
Infant Colic
Reassure is common and tends to self resolve
Information: NHS choices, health visitor
Try holding baby w/gentle motion, white noise
Encourage parents to look after themselves too w/support and sleep
NB. infacol and coleif have insuf. evidence
Appendicitis in paeds
Ix: FBC, urine pregnancy test, CT abdo Surgical emergency: admit, NBM IV fluids appendicectomy (?cefoxitin IV)
Intussusception Ix
USS
AXR if suspecting obstruction
Contrast enema
Intusseusception Mx
ABCDE
?IV fluids/NG feeding
Unless signs of peritonitis attempt rectal air insufflation (w/fluoro guidance by a radiologist)
- 25% will need surgery
Contraindications to contrast enema reduction in intussusception
Peritonitis
Perforation
hypovolaemic shock
Broad spec ABx (clind+gent/tazocin/cefotixin+vanc)
2nd line: surgical reduction w/broad spec ABx
Recurrent intussusception
Consider investigation for pathological lead point eg Meckels diverticulum
PACES counselling of Intussusception
Dx: part of bowel has become stuck to another telescopically
Young children
May need NG/IV
Explain procedures (air insuff. -> operation 25%)
5% risk of recurrence (usually within days of treatment)
Meckel’s Diverticulum
Ix: T99m pertechnetate
Asymptomatic: Incidental finding, no Mx, if detected surgically excise as prophylaxis
Symptomatic:
- bleeding: excise w/trx if Hb unstable
- obstruction: excision and adhesiolysis
- Perforation/peritonitis: excision or small bowel segmental resection + Abx
Malrotation
Ix: upper GI contrast, CT abdo w/contrast, AXR
If signs of vascular compromise: EMERGENCY laparotomy
Ladd procedures derotates the bowel by dividing Ladd band
Duodenojejunal flexure placed on right and caecum and appendix on left (appendix usually removed)
ABx: cefazolin
Recurrent Abdominal pain
Inspect for anal fissure, check growth of child
Urine MC&S
Abdo USS (gallstones, ureteric obstruction)
Coeliac antibodies and TFTs
IBS and functional dyspepsia are Dx of exclusion
Abdominal migraine
offer anti-migraine meds
IBS Advise to parents
Reassure
Encourage patient to ID sources of stress/anxiety or foods that may aggravate symptoms
Peptic ulcer Dx in children
if suspected: lansoprozole 30mg Ix for H pylori If positive;Amox+metroORclari If this fails upper GI endoscopy - if normal: functional dyspepsia
- 7d triple therapy in peptic ulcer Dx:
PPI BD, 1g amoc BD + clari 500mg BD or metro 400 mg BD
If penicillin allergy omit amox and use other 3
Eosinophilic oesophagitis
oral corticosteroids (fluticasone or budesonide)`
Gastroenteritis in children
Assess for: dehydration and shock Consider admission Rehydration ?stool analysis prevent spread FU
Maintenance and Rehydration volumes in children
Maintenance: 0-10kg = 100ml/kg 10-20 = 1000ml + 50ml/kg >10 20+ kg = 1500ml +20m/kg >20 Rehydration <5: 50ml/kg over 4hrs as well as maintenance w/oral hydration solution >5: 200mL ORS after each loose stool
Notifiable gastroenteritis
campylobacter Listeria E coli 0157 Shigella Salmonella
Dehydration in children
likely viral cause
Ix: U+E, FBC, stool MC+S only if bloody diarrhoea
Mx: ORS, IV fluids only for shock, deterioration or persistent vomiting
Fluid resuscitation in children
Glucose free crystalloids w/Na in the range 131-154
Bolus of 20ml/kg over <10m
- different in DKA bc of risk of cerebral oedema
IV fluids monitoring
Glucose and electolytes at least evert 24hr
Neonatal fluid requirements and resus
Maintenance (day): 1: 50-60ml/kg 2: 70-89ml/kg 3: 80-100ml/kg 4: 100-120ml/kg 5-28: 120-150ml/kg for neonates use isotonic crystalloids w/5-10% dextrose
Hypernatraemic dehyration
ORS first line
If IV introduce slowly to avoid cerebral odema
Replace deficit over 48hrs
Antidiarrhoeal and antiemetics in children
NOT used ineffective SE focus away from rehydration increased time sheding bacteria in stool
Gastro indications for Antibiotics in children
NOT routinely gastroenteritis ONLY for: suspected/confirmed sepsis extra-intestinal spread salmonella gastroenteritis if <6m Malnourished or IC children Specific infections: C dif, cholera, shigell
Nutrition after diarrhoea
needs increasing
?Zn deficiency
Post-gastroenteritis syndrome
introduction of normal diet causes watery diarrhoea
start ORS
Coeliac Dx Ix
Ix: FBC+ smear (macrocytic an.),
Serology (anti-tTG, anti-EMA (if IgA def. IgG DGP))
OGD and duodenal biopsy (v. young may have confirmatory EMA + HLADQ2/8 testing instead)
Coeliac Dx Mx
Remove all wheat, rye, barley Referral to dietician Annual r/v: - height, wt, BMI - Sx - Adherence to diet -?bloods (serology, FBC, TF, LFT, vit D/B12, folate, Ca)
Non-adherence to coeliac diet
micronutrient def. (osteopenia)
small increased risk of bowel ca esp small bowel lymphoma
hyposplenism
PACES counselling of coeliac dx
Dx; unable to digest gluten Common 1 in 100 Mx: gluten free diet Dietician Importance of diet FU necessary every 6-12m Regular height and weight measurements Support: coeliac UK
Crohns Dx Ix
FBC (inc. Fe, B12, folate) CRP + ESR ?Stool testing Upper GI and small bowel contrast scan Colonoscopy and biopsy ask about impact on life
Education for Crohns pts
Stop smoking (Reduce relapse) risk of osteoporosis unintended wt loss could be sign of flare do NOT have live vaccines if on IS Mx
Medical Mx of Crohns Dx
Steroids (pred) to induce and maintain remission
IS drugs (azothioprine, MTX)
Biologics (infliximab)
Aminosalycates (mesalazine)
PACES Counselling of Crohns Dx
Dx: unkown cause, inflammation, malabs, diarr. Life long w/relapses Mx by gastroenterologist medically Cx: malabs and cancer no special diet but may find triggers Suport: Crohns and Colitis UK
Ulcerative colitis Assessed by:
Paediatric ulcerative colitis activity index (PUCAI)
Sev: >65pts
Mild-mod:>10-64
Mild-moderate proctitis in UC in children
Oral and/or topical aminosalicylates
Second line: topical corticosteroid or pred PO
Mild left sided and extensive UC in children
PO aminosalicylate
consider adding topical AS, PO beclometasone
Alternative: PO pred
If no improvement after 4 wks of aminosalicylate therapy in UC in children
Consider adding oral pred if still no: PO tacrolimus biologicals: infliximab, adilimumab - surgery and option
Maintaining remission in UC in children
AS mainstay
consider PO azothioprine or mercaptopurine if requiring steroids freq.
Severe fulminating UC in children
EMERGENCY - do they need surgery? Increased risk of needing surg: >8 stool/day Pyrexia tachycardia AXR w/colonic dilatation Low: albumin, HB, High: plt. CRP Offer IV corticosteroids to induce remission (second line ciclosporin)
Surgical Mx of fulminating UC in children
Colectomy w/ileostomy or ileojejunal pouch
PACES for UC
Unknown cause, inflammation of bowel -> Sx
1:420
No cure, Dx will come and go
Medications available to reduce flares and treat when they happen
Cx: growth issues, bowel ca
FU: will be seen by gastroenterologist
Constipation in children
Exclude red flag symptoms
Laxatives (several mo. possibly)
Examine for impaction (commence disimpaction is present)
Otherwise: maintenance laxative rx
Behaviour intervention (gastrcolic reflex, star chart)
Diet and lifestyle (hydration)
FU to assess response
Disimpaction therapy
step 1: movicol paed plan (polyethylene glycol + electrolyte) escalating dose 2w
step 2: Add a stimulant (senna/sodium picosulphate)
- If movicol not tolerated a stimulant can be used w/lactulose or docusate (softners)
Maintenance therapy for constipation in children
Movicol +/- stim. laxative
Reduce dose over monthsi in respoonse to improvement
Types of laxative
Bulk forming: fybogel, methylcellulose
Osmotic: lactulose, movicol
Stim.; Bisacodyl, senna, sodim picosulphate
stool-softener: arachis oil, docusate
All else fails constipation in children
enema
manual evacuation under anaesthetic
Constipation in under 1yr old
Increase fluids
lactulose
neonates may not poo for days if they are absorbing milk like nobody’s business
PACES of Constipation in children
Simple constipation is very common Mx: break cycle or hard stool to pass Takes time for movicol to work - disimpaction 2w escalating dose - maintenance long term until habits reestablished Encourage gastrocolic reflex Behavioural motivation interventions emphasises is safe long term, most common cause of failure is inadqeuate use Aim: 1+ large soft stool
Hirschprung Dx Ix
AXR (if obstructed), contrast enema (narrow aganglionic segment)
Definitive: full thickness rectal biopsy
Hirschprung Dx Mx
Initally bowel irrigation
Surgical: colostomy followed by anastamosis of innervated bowel and anus
aka anaorectal pull-through
Total colonic agangliosis would require initial ileostomy w/later corrective surgery
Anal fissure in children
Ensures stools soft (fibre, fluids, ?laxative)
Pain: simple analgesia, warm bath
Importance of anal hygiene
Advise against stool holding
IF not improved in 2w or significant pain present again
consider topical anaesthetic or GTN
Threadworm in children
Exclusion NOT required
Single dose of mebendazole (repeat in 2wks if persistent)
Children <6m hygiene alone, <6w seek ID specialist
Trace contacts
Rigorous hygiene 2wks if medendazole, 6wks if hygiene alone
Rigorous hygiene for threadworm
Hand washing
cut nails regularly, avoid scratching anus
shower each morning and wash perineum
Change bed linen and nightwear nightly for several days (do NOT shake and wash on hot cycle)
dust and vacuum
