Gastrointestinal Disease Flashcards
What are the key differences between the adult and child GI tract?
What systemic diseases commonly haave gastro-intestinal manifestations?
- diabetes ie DKA → acute abdo pain
- sickle-cell + Henoch-Schoenlein disease → acute abdo pain
- migraine → vomiting + abdo pain
- raised ICP → vomiting
- septicaemia + meningitis → mimics gastroenteritis
- cystic fibrosis → pancreatic insufficiency
Why are children vulnerable to malnutrition?
- low nutritional stores of fat + protein
- growth creating high nutritional demands
- brain growing rapidly during first 2yrs of life + is vulnerable to energy deprivation
Why are children at particular risk of dehydration?
- greater surface area to volume ratio → greater insensible water loss
- inability to gain access to fluids when thirsty
- higher basal fluid requirement (10-20% of body weight per day)
- immature renal reabsorption process
What is the difference between gastro-oesophageal reflux (GOR) and gastro-oeseophageal reflux disease (GORD)?
- GOR is the effortless passage of gastric contents into the oesophagus +/- regurgitation and vomiting, it is a normal physiological occurrence especially common in infants
- GORD refers to either the symptomatic regurgitation of gastric contents into the oesophagus or GOR w/ complications, GORD commonly presents in infancy w/ a prevalence of 4.3% at 6 months old
What is the aetiology behind gastro-oesophageal reflux?
- laxity of LOS → in infants it is partly due to immaturity of the LOS, symptoms improve as the sphincter tone increases, a more solid diet is introduced + child spends more time in an upright posture
- food allergy or intolerance
- foregut intestinal dysmotility associated w/ gut inflammation or neurological disorder
- increased gastric pressure → due to a more distal intestinal obstruction, obesity or chronic respiratory disorders
It is important and can be challenging to distinguish between GOR and GORD in infants. Frequent, effortless regurgitation of feeds is normal and there is no reliable investigation to distinguish between the two.
What are clinical features of GORD?
- persistent/recurrent regurgitation, particularly after meals
- feeding difficulties, food refusal +/- crying/irritability post feeds
- arching of back + neck in infants
- resp symptoms, such as coughing + wheezing
- sore throat + hoarseness
- apnoeic/bradycardic episodes
- heartburn/chest pain
- faltering growth
O/E check for: hydration, malnutrition, abnormalities indicating a differential diagnosis, assess growth charts
For GORD diagnosis, it is important to take a full feeding history - what should be involved?
- check position, attachment, technique, duration, frequency + type of milk
- calculate the volume of milk being given as babies can be over-fed + therefore have gastric over-distension
- ask about frequency + estimated volume of vomits
- find out the relationship of symptoms to feeds
What is the difference between possetting, vomiting and gastro-oesophageal reflux?
- Posseting refers to bringing up small amounts of milk after a feed (often on burping). It causes no pain or discomfort and is no cause for concern if the baby is happy, feeds well and fains weight. It usually settles at around 5 months when the baby is sitting
- Vomiting is active, forceful contractions through the GIT to bring up stomach contents (could be more solid in nature)
- GOR is when milk or stomach acid may only be regurgitated as far as the oesophagus or throat. This form of reflux does cause the baby discomfort and there is usually disruption of feeding, and possibly sleeping patterns. Baby may cry during or after a feed, pull off the breast, arch his back, become rigid, writhe, kick or throw out his arms.
GORD in older children may be identified w/ a typical history and physical examination. In challenging or complicated GORD, further investigations can aid understanding the cause and severity of the disease.
What investigations can be done?
- Bloods → FBC, U+Es, ABG
- pH impedance study → measures pH as well as non-acid reflux in oesophagus by placing probe in stomach, benefits infants on milk feeds w/ non-acidic reflux that won’t be detected on “pH” but will on “impedance”
- Endoscopy → upper GI endoscopy + biopsies
- Oseophageal + antroduodenal manometry
- Abdo USS
- Barium contrast study
Effortless regurgitation in otherwise well infants is common. Approximately 40% of infants will experience this and no intervention is necessary. Symptoms should have started in the first 2 months of life and usually improves with age until they are 1 years old. Reassurance is key.
What is the conservative and medical management for GORD in children?
- optimise position by raising the cot base at the head end by 30 degrees
- avoid over-feeding + consider smaller, more frequent meals
- use feed thickeners
- ensure adequate nutrition w/ regular monitoring of weight
- for babies w/ suspected GORD:
- if breastfed → 1-2wk trial of an antacid (eg. gaviscon infant)
- if formula-fed → see image of stepwise approach
- if above doesn’t work → 4wk trial of ranitidine or omeprazole
If symptoms persist for GORD after medical treatment, what is the surgical management?
-
Nissen’s fundoplication (uses top of stomach to strengthen LOS) may be considered in:
- older infants
- children w/ severe GORD unresponsive to med therapy
- children who have previously suffered or are at increased risk of ‘life-threatening’ events like aspiration pneumonia and apnoea
What are the differentials for acute abdominal pain, of medical nature?
- infant colic
- constipation
- mesenteric adenitis
- gastroenteritis
- hepatitis
- UTI
- DKA
- sickle cell
- lower lobe pneumonia
- henoch-schoeinlein purpura
What are the differentials for acute abdominal pain, of surgical nature?
- appendicitis
- intussusception (intestinal obstruction)
- ovarian or testicular torsion
- strangulated inguinal hernia
- volvulus
- inflamed meckel’s diverticulum
- peritonitis
- trauma
What are differentials for recurrent abdominal pain?
- usually functional
- UTI
- obstructive uropathy
- food intolerance
- IBD
- ulcer
- malrotation
- pancreatitis
- coeliac disease
- CF
- porphyria
- lead poisoning
Upon taking a thorough history of the presenting complaint, what clinical features may be present in an acute abdomen?
- babies - screaming + drawing up of legs
- pain lasting for >4 hrs → significant
- nature: consistent, colicky, intermittent
- vomiting: bile or blood stained
- diarrhoea → blood in infant suggests intussusception, older child IBD
- anorexia: normal appetite → sign of wellbeing
- fever implies infection → eg. UTI, mesenteric adenitis, appendicitis
- urination: pain → UTI
- symptoms of LRTI → pneumonia
- rash → HSP
- look at hernial orifices
- look at genitalia
- check hip joints
What investigations can be done for the acute abdomen?
- bloods → FBC + WBC (bacterial infection), sickling test, U+Es, glucose
- urinanalysis → glucose, ketones, infection
- AXR → constipation, renal calculi, obstruction
- USS → obstructive uropathy, appendix mass, intussusception
What is mesenteric adenitis?
- often accompanied by URTI w/ cervical lymphadenopathy
- second most common cause of RLQ pain after appendicits
- definitive diagnosis can only be made during a laparotomy or laparoscopy if enlarged mesenteric lymph nodes + normal appendix is seen
- resolves in 24-48hrs
What is intussusception?
- invagination of proximal segment of bowel into another more distal part
- occurs most commonly in infants aged between 2 months - 2 years
- majority of cases occurring before the first b’day
- males at higher risk (3:2)
- most cases are idiopathic, condiiton is more common in winter + spring suggesting a link to viral infections (gastro, resp infections)
- in up to 10% cases, a pathological lead point found → meckel’s, Peutz-Jeghers polyps + small bowel lymphoma
What investigations can be done for intussusception?
- blood tests → inflammation, electrolyte derangement, dehydration + significant bleeding
-
ULTRASOUND → gold standard
- classic sign is the “target sign” (or doughnut sign) on transverse section
- represents two concentric lumina of bowel
- an AXR may reveal features of small bowel obstruction
What investigations are done for coeliac disease?
- FBC, LFTs
- iron studies, vit b12, folate
- U+Es, bone profile, magnesium
-
tissue transglutaminase antibody (tTGA) then IgA endomysial antibodies (EMA)
- pt needs to have included gluten-containing foods in diet over prev 6 weeks
- if +ve serology → referred to endoscopy + intestinal biopsy
- if -ve serology → IgA serology to check for IgA deficiency (may mask positive test)
- upper GI endoscopy (gold std) → histological findings include atrophic villi + crypt hyperplasia
What are the features of a congenital diaphragmatic hernia?
- normally a left-sided herniation of abdominal contents through posterolateral foramen of diaphragm
- heart will be displaced to the right
- there will be poor air entry in left side of chest
- diagnosis made on plain film xray after birth or antenatal USS
- newborns may have RDS or show failure to respond to resuscitation
- NG tube passed down + suction is done to prevent distension of intrathoracic bowel
- after stabilisation → hernia surgically repaired
- surgical correction attempted when foetus is 22-24wks gestation in utero to prevent death from lung hypoplasia, however it can precipitate pre-term delivery
IBD usually presents in adolescence and early adulthood. IBD in children generally has a more extensive + rapidly progressing course. Children often present acutely, but at presentation patients often report long-standing symptoms.
What is the presentation of IBD?
For BOTH:
- incrased freq of bowel movements
- abdo pain
- weight loss
- n+v
- faltered growth
- delayed puberty
- reduced appetite
- malaise/fatigue
- sweats
- clinical signs: fever, tachycardia, dehydration, pallor
What is the treatment for IBD?
Summarise the key differences between Crohn’s and UC
