Gastrointestinal and surgery Flashcards
which type of inflammatory bowel disease is more common in children?
Crohns
discuss the pathology of crohns disease?
- transmural inflammation with non-caseating granulomas
- most commonly effects the terminal ileum, but may occur anywhere from mouth to anus
local complications of crowns?
- strictures
- adhesions
- fistulas
- abscesses
how does crohn disease most commonly present? 3
- weight loss
- diarrhea
- abdominal pain
extra-intestinal features of IBD?
erythema nodosum
pyoderma gangrenosum
uveitis
arthritis
potential systemic features of IBD
anemia, tachycardia, fever
diagnosis of IBD?
- gold standard is colonoscopy and biopsy
- FBC for anemia, CRP and ESR are also elevated
- stool cultures often necessary to exclude infective causes of colitis
how is the severity of IBD determined? name of the scale and what does it take into account
Paris classification
age at diagnosis
location of involvement
behaviour of disease
Childs growth
management of IBD active disease?
anti-inflammatories: sulfalazine (DMARD) and Mesalazine
management of relapses of IBD
- steroids
- immunosuppressants to maintain remission: azathioprine
when to consider biologics for IBD?
treatment resistant cases
which biologic is commonly used in treatment resistant IBD
infliximab (TNF-alpha inhibitor)
define celiac disease?
autoimmune disease caused by an abnormal response to the gliadin component of gluten
How may celiac disease present in a young child? 2
1) failure to thrive
2) abdominal distension
how may celiac disease present in a older child?
weight loss
buttock wasting
what are other features of celiac disease? 3
anemia
steatorrhea
micronutrient deficiencies (iron, folate, vitamin D, calcium)
what rash is associated with celiac disease?
dermatitis herpetiformis
what are other conditions associated with celiac disease?
other autoimmune conditions (diabetes, hashimotos)
what is the gold standard for diagnosis of celiac disease? what does it show?
duodenal biopsy which shows villus atrophy and crypt hypertrophy
how can celiac disease be diagnosed by serology ?
elevated IgA tissue transglutaminase autoantibody. IgG can also be used if the patient has IgA deficiency. IgA anti-endomysial antibody can also be used
what blood tests besides autoantibodies do you want in someone with suspected celiac?
FBC - for anemia
vitamin D
calcium
iron studies
management of Celiac disease?
Gluten free diet
supplementation of deficiencies
complications of celiac (from non-adherence to gluten free diet)
- micronutrient deficiencies
- osteopenia
- bowel lymphoma
what is a differential diagnosis in someone who presents with a clinical picture suggestive of celiac disease + signs of infection ? what is the management
giardia lamblia
metronidazole
what is something that is often confused with GERD? how common is it? and when does it usually resolve
simple reflux
occurs in 40% of infants after feeds and resolves by 1 year
when is GERD considered a disease in children?
if occurring with complications:
1) failure to thrive
2) esophagitis/esophageal stricture
3) aspiration pneumonitis
4) Sandifer syndrome
what is Sandifers syndrome?
a manifestation of GERD which imitates seizures. causes a child to adapt an opisthotonic posture with dystonic neck and trunk movements in reaction to acidic reflux
what are predisposing factors for GERD in child?
1) cerebral palsy
2) neurodevelopment disorders
3) bronchopulmonary dysplasia
4) post-surgery
what is the management of GERD in a infant?
- simple measures such as smaller feeds, winding, and keeping the baby upright
- adding thickeners to feeds (carobel)
- if not improving consider other causes such as cow milk protein allergy
- last line treatment: Nissen fundoplication surgery
how can cows milk protein allergy be divided?
IgE and non-IgE mediated
presentation of non-IgE mediated cows milk protein allergy?
1) causes delayed gastrointestinal symptoms
2) over time leads to a failure to thrive
presentation of IgE mediated cows milk protein allergy
causes immediate symptoms including
1) wheeze
2) conjunctivitis
3) angioedema
4) also GI symptoms
what is the management of cows milk protein allergy?
management is by avoiding cows milk and substitution with a hydrolyzed formula
what does trachea-esophageal fistula commonly occur with ?
esophageal atresia
presentation of tracheo-esophageal fistula ?
frothy and choking newborn (often with polyhydraminos), nasogastric tube cannot be passed
how is tracheo-esophageal fistula diagnosed?
chest x-ray
management of trachea-esophageal fistula?
surgical correction
what is tracheo-esophageal fistula associated with?
VACTERL syndrome
components of VACTERL syndrome
- vertebral anomalies
- anorectal anomalies (anal atresia
- Cardiac anomalies
- tracheoesophageal fistula
- renal anomalies
- limb anomalies
what age range does pyloric stenosis usually occur in ?
3-12 weeks
presentation of pyloric stenosis ?
1) projectile non-bilious vomiting
2) olive-like mass palpable superficially at the epigastric region (level of the pylorus)
what are the metabolic consequences of repetitive vomitting?
hypokalemic hypochloremic, metabolic alkalosis
what is the management of pyloric stenosis ? it is an emergency?
yes it is a surgical emergency
1) ABCs + IV fluids + electrolyte correction (remember the role of Cl- in correcting the metabolic alkalosis)
2) surgery
name of surgical intervention required to treat pyloric stenosis ?
ramstedt pyloromyotomy
presentation of duodenal atresia ?
presents postnatally with bilious vomitting
are most cases of duodenal atresia isolated lesions?
yes
30% of cases of duodenal atresia occur with??
trisomy 21
diagnosis of duodenal atresia ? what does it show
plain film x-ray
double bubble sign
management of duodenal atresia ?
- ABCs + IV fluids + electrolyte correction
- surgery: duodeno-duodenostomy
presentation of volvulus?
- bilious vomitting
- abdominal distension
- PR blood
- often in shock
what is mid-gut volvulus associated with?
malrotation of the midgut
diagnosis of mid-gut volvulus?
upper GI series
management of volvulus?
emergency ?
- ABCs, IV fluids, electrolytes
- surgical emergency
what age range does intussusception usually occur in ?
6 months to 2 years
presentation of intussusception?
- intermittent abdominal pain
examination may show sausage like mass in the abdomen - screaming with drawn up legs and passing “redcurrant jelly” stool
- vomitting
diagnosis of intussusception?
ultrasound showing “donut sign”
management of intussusception ?
- ABCs
- air enema or surgery
define gastroschisis?
abdominal wall defect occurring to the right of the umbilical cord insertion without a covering of membrane
gastroschisis is associated with? 3
- intrauterine growth restriction
- prematurity
- low birth weight
gastroschisis is more common in young mothers taking ….?
recreational drugs
management of gastroschisis?
surgical repair
what is the feared complication of surgical reduction of gastroschisis ?
abdominal comparent syndrome leading to organ ischemia
what defines minor vs major omphalocele (exompthalmos)
size: minor < 5cm, major > 5cm
omphalocele is associated what genetic syndrome?
Beckwith-Widemann syndrome (organomegaly)
minor omphalocele is often mistake for…?
umbilical hernias
in a patient with an omphalocele it essential to do a …. and ….. to exclude other disorders??
echocardiogram
genetic karyotyping
management of omphalocele ?
minor: surgical closure
major: staged surgical closure
define hirschprung disease?
congenital absence of ganglionic cells in the distal rectum. failure of migration of neural crest cells
classic presentation of Hirschprung disease?
distal obstruction causing bilious vomiting and a failure to pass meconium within 48 hours
diagnosis of hirschprung’s disease ?
- barium enema (dilation) of proximal segment and distal narrowing
- rectal biopsy
management of Hirschprung’s disease?
resection of the affect bowel segment
define necrotizing enterocolitis?
acute ischemic necrosis of the intestines occurring mostly in premature infants <32 weeks
presentation of NEC?
abdominal distension
bilious vomitting
blood PR
predisposing factors for NEC?
Patent ductus arteriosus
cardiac surgery
sepsis
management of NEC?
- NPO + TPN + Antibiotics for 10 days
- Surgery if perforated
diagnosis of NEC?
gold standard is abdominal X-ray which may show air in the wall of the bowel wall (pneumatosis intestinal, dilation of the bowel, portal venous gas
what is the differential for bilious vomitting in a new born? 3
- severe gastroenteritis
- NEC
- distal obstruction including; duondenal atresia, meconium ileum, Hirschprung disease, volvulus
differential for non-bilious vomitting in a newborn? 3
- mild gastroenteritis
- GORD
- pyloric stenosis
