Gastrointestinal/abdominal Flashcards
What’s the management for constipation with soiling?
- Osmotic laxatives - movicol (can use stimulants once stools are soft) for ~2 weeks
- Keep stools soft through diet/laxatives for a further 3-6 months - encourage daily bowel movements
Why do preterms <34 weeks require NG tube/TPN?
They have no suck/swallow reflex
Why do babies lose weight in the first couple weeks of life?
They use up there liver glycogen stores - should lose around 5-7% of their birth weight. Worrying if still under birth weight at 2 weeks.
What are the benefits of breastfeeding?
Lower incidence of SIDS, NEC, IDDM and GI infection Contraceptive effect Cheaper Improves cognitive development Assists attachment
What are the cons of breastfeeding?
Can transit maternal infections (CMV and HIV)
Can transmit medications and metabolites e.g. anti-epileptics
Only mum can feed the baby
Can become vit A/D deficient if solely breastfed for >1yr
Inaccurate volumes of feed
Whats the recommended time to start weaning?
6 months
What might indicate an infant is suffering from gastro-oesophageal reflux?
Vomiting +/- aspiration FTT Irritability and anorexia Opisthotonos (arching of back) apnoeas
When should pharmaceutical therapy be offered in an infant with GOR? what should be offered?
When GOR occurs with one of the following:
FTT
Distressed behaviour
Unexplained feeding difficulties e.g. food refusal
4 week trial of PPI or H2 antagonist should be offered e.g. ranitidine
What is rumination?
Chronic regurgitation
What are worrying features in a vomiting child?
Bilious vomit Blood stained vomit Drowsiness Food refusal Malnutrition and dehydration
How would you check the hydration status of a infant?
Skin turgor - pinch skin - skin folds persist in dehydrated child (>2secs in severe dehydration)
Sunken fontanelle and eyes
Dry mucous membranes
Sleepy/lethargic indicates severe dehydration
Decreased UO
What is the usual cause of blood stained diarrhoea in a child with gastroenteritis?
Camplylobacter or E. coli
When should antibiotics be given to treat gastroenteritis?
When the child has been abroad or there is extra-intestinal involvement/septicaemia
Outline fluid management in a child with gastroenteritis
Continue breast-feeding
Encourage fluid intake - can use ORS if clinically dehydrated
If severely dehydrated - IV fluids
NICE fluid challenge: 50mls/kg in 4 hours - send home if obs normal
Saftey-netting:
- if they are not waking properly inbetween sleeps
- fi they are not urinating/drinking >50% o normal
- fitting
When would you do further investigations (stool sample, bloods) in a child with gastroenteritis?
When the child has been abroad Immunocompromised Acutely unwell/septic Blood and mucus in stools Diarrhoea persists >7days
Acute causes of abdominal pain in children?
Appendicitis Gastroenteritis Malrotation/volvulus Intersusseption UTI Testicular torsion HSP Hirschsprung's Dysmenorrhoea Poor localisation of pain e.g. pneumonia Abdominal migraine
What is RAP?
Recurrent abdominal pain - present continuously, or occurring at least on a weekly basis when intermittent, for a minimum period of two months - normally in the peri-umbilical area
Particularly important features of acute appendicitis?
Anorexia and a great reluctance to move (due to pain)
Essential investigations in acute appendicitis?
FBC, U+Es and urea
What is the pathophysiology of coeliac’s?
Body creates antibodies to gliadin (gluten) –> billi destruction –> villous atrophy, crypt hyperplasia and malabsorption
What stool presentation would fit wit coeliac’s?q
Steatorrhoea and foul smelling
Presentation of coeliac’s in child <2yrs?
FTT, irritability, anorexia, vomiting, diarrhoea
Abdominal distention, buttock wasting, pallor
Why should coeliac’s patients be offered the pneumococcal vaccine?
May have a degree of functional hyposplenism
What type of inguinal hernia is more common in children and why is this so?
Indirect hernias (through the deep inguinal ring) - patent processus vaginalis
When would emergency surgery be required for inguinal hernia repair?
When the hernia becomes irreducible and incarcerated - risk of bowel obstruction and ischaemia as the blood supply is cut off (strangulation)
NB. in first few months of life this is much more likely so inguinal hernias should always be surgically repaired as a matter of urgency for this age group
What is the pathophysiology of intussusception?
Immature gut = increased no. of peyer’s patches and immature gut flora –> (infection - gastroenteritis/URTI) –> inflammed peyer’s patches become lead point of invagination (usually at oleo-caecal junction) and bowel wall distends –> cuts off venous return –> congestion –> oedema and bleeding –> redcurrent jelly stool
What is the clinical presentation of a baby suffering from intussusception?
5-18 months (usually 9-12), B>F 2:1
Episodic pain + pallor (episodes of extreme crying, child brings knees up to abdomen and turns pale) +/- vomiting +/- redcurrent jelly stool (late and worrying sign)
Examination will reveal sausage-shaped mass in RLQ
Investigation - Abdo USS - shows target sign
Management of intussusception?
Investigation = USS
NBM and drip+suck
Initially try ‘air enema’ (air insufflation) under radiological control- forces back the invaginated bowel
Surgical repair is indicated if there red current jelly stool/ necrotic bowel/peritonitis that needs to be resected
What should a child be investigated for if there is recurrence of intussusception?
Polyps
How is a diagnosis made between mesenteric adenitis and appendicitis?
Dx of mesenteric adenitis only made upon laparotomy
Clues are peritonism, no guarding, preceded by ‘flu like’ illness and a high temperature of >38.5 (appendicitis = <38.5)
Management of mesenteric adenitis?
Self - limiting - cna give analgesia
Educate parents - reassurance and to observe symptoms
What is NSAP?
Pain (less severe than appendicitis) preceded by a URTI
Self-limiting (usually 1-2 days)
What is pyloric stenosis and when does it usually present?
Congenital obstruction of the pyloric sphincter by pryloric muscle –> projectile vomiting after feeds –> v hungry and dehydrated babies
Usually presents at 4-8 weeks, M>F = 4:1 (more common in first born) - can present up to 4 months
Differentials: reflux, cows milk allergy, gastroenteritis
When should an ultrasound be performed in suspected pyloric stenosis?
When an olive shaped mass cannot be felt on palpation
*Watch and feed before
What might be found on VBG in a baby with pyloric stenosis?
Hypochloraemic alkalosis
- low potassium
- low/normal sodium
- low chloride
What is first line treatment in a baby with pyloric stenosis?
Correction of fluid and electrolyte imbalance - fluids + electrolytes i.e. >90 micromols of Cl-
Can then operate - open (Ramstedt’s procedure) or laparoscopic
Pathophysiology of testicular torsion?
Adolescents - ‘bell clapper testes’ (free to move and twist) results in intravaginal torsion –> twisting of epididymis –> pain +++, N+V, acute and tender unilateral testicular swelling +/- erythema
Neonates = extravaginal torsion - testes fixed to scrotum - tunica vaginalis + spermatic cord twist –> firm and non-transilluminable mss
Management of testicular torsion?
emergency exploratory surgery - must be corrected with 6-12hrs
Risk factor for undescended testes?
Prematurity - descent occurs in 3rd trimester - often have inguinal hernia also due to patent processus vaginalis
Types of undescended testes?
Cryptorchidism - unilateral
Anarchism - bilateral
Palpable - 80% - usually at superficial inguinal ring - can try to manipulate testicle down to scrotum
Impalpable (Intra-abdominal) - 20% - increased risk of malignancy
retractile - creamster reflex –> testes move up inguinal canal - resolves with age
Management of undescended testes?
If testes cannot be manipulated into the scrotum then either a normal orchidopexy (palpable) or a 2-stage orchidopexy (+ ligation of patent processus vaginalis) needs to be carried out before the age of 2yrs
What is crohn’s and how is it managed?
IBD - mouth to anus, typically terminal ileum –> weight loss, fever, recurrent abdo pain, bloody diarrhoea, mouth/peri-anal ulcers, arthritis, erythema nodusum
Management 1st = polymeric (high protein) diet works 75% 2nd = High dose steroids Maintenance immunosuppressants (azathioprine) +/- anti-TNF agents (infliximab)
What is ulcerative colitis and how is it managed?
IBD - colon and rectum –> bloody + mucus diarrhoea, rectal bleeding, weight loss, pain, arthritis, liver isturbance
Inducing remission in children - oral aminosalicylate +/- topical aminosalicylate or beclometasone
If no improvement in 4 weeks add oral prednisolone (and remove beclametasone)
Maintenance - daily oral aminosalicylate
What investigations should be done in IBD?
Bloods - FBC, CRP + ESR (raised), albumin
Endo/colono-scopy + biopsy
UC = mucosal inflammtion, crpt damage and ulceration
Crohn’s = Noncaseating epitheloid granuloma
What is biliary atresia and what are it’s consequences?
Obstrcution of the extrahepatic biliary tree +/- intrahepatic biliary ducts (graded 1-4)
Results in obstructive jaundice after 2-8 weeks - high conjugated fraction Pale stools (after meconium) FTT - deficient in fat soluble vitamins Easily bruised
What investigations should be done in biliary atresia?
Bloods - FBC (anaemia), Clotting factors (low), APTT high, Bilirubin - high conjugated fraction (>20%)
Imaging - USS
Liver biopsy
Laparotomy = GOLD STANDARD
Management of Biliary atresia?
Surgery - kasai procedure (direct attachment of small bowel to liver) - 80%
If unsuccessful = liver transplant
What are the symptoms of hepatitis A and how is it managed?
Insidious onset of nausea, vomiting, RUQ pain, anorexia and jaundice
Self-limiting agter 2-4 weeks, close contacts need HNIG (public health)
Diagnosis = high liver enzymes, high conjugated bilirubin and virus serology
How is hepatitis B transmitted to babies and how is it managed?
Vertical transmission - immunize at risk babies at birth + immunoglobulins
When does malrotation usually present, what is the pathophysiology?
First few days of life
Short or inadequate attachment of the mesentery to bowel (usually caecal), LADD bands constrict the duodenum –> malrotation and obstruction –> bilious vomiting, abdo pain and anorexia
What is merkel’s diverticulum?
Pouch in the terminal ileum that is a remnant of the vitello-intestinal duct –> PR bleeding (can develop volvulus, obstruction and intussusception)
Technetium scan detects gastric mucosa (present in 60% cases)
Removed surgically
What is Hirschsprung’s disease?
Lack of nerve supply (myenteric and submucosal ganglia) to rectum and colon –> Instestinal obstruction (bilious vomiting, abdominal distention, delayed meconium, consipation and FTT) in first few days of life
Rectal biopsy will confirm the absence of ganglion cells
Surgery - colostomy initially, anatomize innervated bowel
What is toddler’s diarrhoea?
‘peas and carrot’ diarrhoea = immaturity of the childs gut
How would you assess nutrition (/malnutrition)?
Diet diary/history
Anthropometry - weight, height, upper arm circumference, triceps skin fold thickness
Bloods - albumin, vitamins/minerals, immunodeficiency (low WCC)
What is marasmus and Kwashiorkor?
Manifestations of protein malnutrition:
Marasmus = inadequate energy in all forms (including protein)
Kwashiokor = adequate energy, deficient albumin/protein
What is Rickets a complication of?
Vitamin D deficiency –> decreased calcium absorption in gut –> low serum calcium –> increased PT hormone secretion –> Increased bone resorption –> failure of bone mineralisation
Symptoms of rickets?
FTT/short stature
Misery
Hyocalcaemia - tetany/seizures
Bowed legs
Signs of rickets?
Harrison’s sulcus - indrawing when diaphragm meets ribs
Frontal bossing (protruding forehead)
Expansion of the metaphyses in the wrist (seen on x-ray)
Bow legs
Investigations in rickets?
Diet diary
Bloods: serum calcium +/- albumin (low) Phosphorus (low or normal) Parathyroid hormone (high) ALP (usually +++) LFTs and U+Es to exclude contributing pathology
NEC abdominal x-ray signs
Intraluminal gas
Free gas - ‘football sign’ (as baby won’t be sat up - you’d normally see it under the diaphragm)
NEC
Most common GI emergency in neonates - low birth weight and prematurity increase risk
(only 10% cases occur in term infants)
Presents 3-10 days of life: Abdo distention Bloody stools, bilious vomting Erythema Bradycardia, shock Apnoea, resp distress
Initial management of NEC
NBM for 14 days- NGT + IVI (can use TPN)
IV Abx for 10 days - amox, gent and met
Oxygen
If unsure of Dx - give 10 days NMB and 7 days Abx
Complications of NEC
Perforation Short bowel syndrome Strictures Abscesses Fistulae Recurrence
75% of children survive (worse prognosis in infants weighting <1.5kg)
What is protective against NEC?
Breast milk (important to push parents!) 3-10 x protective
Signs for pyloric stenosis
Small for age
Visible stomach persitalsis
Palpable pylorus
VBG - metabolic alkalosis (low potassium and chloride)
Complications of hirschsrpung’s
Soiling Enterocolitis - can be fatal (inflammation and infection in the bowel - treat quickly with broad spec Abx and NBM) Obstruction Incontinence Constipation Stricture
Most patients eventually require normal bowel function
Management of hirschprung’s
Surgery
Early = anastomoses
Late = stoma
