Gastrointestinal disorders in Childhood Flashcards
what are the causes of abdominal pain
- Constipation
- Functional/RAP (recurrent abdominal pain)/IBS
- Duodenal ulcers/Helicobacter Pylori
- Inflammatory Bowel Disease
what are the causes of chronic vomiting/haemetemesis
- GOR.
- Intestinal Obstruction (if bile) intermittent.
- DU (rare).
what are the causes of chronic diarrhoea
• IBD
.
What are the causes of failure to thrive/weight loss
- Coeliac
* Cystic Fibrosis
what are the causes of rectal bleeding/blood stools
- IBD
- Chron’s/UC
- Fissures/haemorrhoids
- Polyps/polyposis syndromes
- Infection (bacterial).
what are the symptoms of IBD
o Weight loss
o Abdominal pains
o Tiredness
o Rectal bleeding
what is the normal bowel habit of young children
- 85% of 1 to 4 year olds pass stools once or twice a day
* 96% do so three times per day to once every other day
what are functional GI disorders
- There are GI symptoms with no evidence of inflammatory, anatomic, metabolic or neoplastic processes that explains the subject’s symptoms
what is the definition of constipation
– Infrequent, hard stools (or difficulty/delay in defecation leading to distress)
what is the definition of soiling
– Escape of stool into the underclothes
what is the definition of encopresis
– The passage of normal stools in abnormal places
How many stools do you pass less than for consptiation
o Passing less than 3 stools per week
OR if painful bowel movements due to hard/large stools and stool retention in spite of passing >3 times per week.
describe the idiagsnotci criteria for functional constipation
Must include 2 or more of the following occurring at least once per week for a minimum of 1 month with insufficient criteria for a diagnosis of irritable bowel syndrome:
(1) 2 or fewer defecations in the toilet per week in a child of a developmental age of at least 4 years
(2) At least 1 episode of fecal incontinence per week
(3) History of retentive posturing or excessive volitional stool retention
(4) History of painful or hard bowel movements
(5) Presence of a large fecal mass in the rectum
(6) History of large diameter stools that can obstruct the toilet
what is the presentation of constipation
- ‘Diarrhoea/soiling, most common in younger age group
- Infrequent bowel movements 58%
- Painful bowel movements 77-86%
- Palpable rectal abdominal mass 66-77%
- Acute abdominal pain
- Recurrent UTI (3.7-30%).
why is constipation a function GI disorder
• No physical or physiological cause
how many pre-school children are affected by constipation
• >90% of pre-school children.
what are organic causes of constipation and how would you investigate them
- Hirschsprungs - rectal biopsy
- hypothyroidism - growth failure so check TSH
- neurologic - examines the spine and lower limbs
- anal stenosis - examination
How do you examine someone with constipation
- Failure to thrive.
- Distended abdomen
- Abnormal anus, empty rectum on PR found in Hirschsprungs.
- Sacral dimples, other neurological abnormalities.
How do you explain the causes of constipation to someone
– Reassure not organic disease
– length of treatment is long if they have had consitpation for long(12 plus months)
– explain that Diet could have an impact (5 units etc)
How to you treat consitpation
- use high dose laxatives or enemas to clear out then use maintenance therapy Maintenance therapy • Softener – Movicol (PEG 4000) • Stimulant – Senna or picosulphate • Rectal washout - Enemas/Peristeem
What is GORD
Passive regurgitation of gastric/duodenal contents into oesophagus
what muscles does vomiting involve contraction of
Vomiting involves active contraction of diaphragm and abdominal muscles
what does reflex present like with children who are greater than three years old
- heart burn
- brash
- vomiting
- oesophagi’s
- usually have history of reflux as an infant
what is the objective and subjective symptoms that GORD can cause
– Objective damage (oesophagitis)
– Subjective severe symptoms (vomiting/heartburn etc)
what are the RED flags and pink flags for GORS
Red Flags o Haemetemesis o Failure to thrive o Sandifers syndrome (back arching in infants) o Aspiration pneumonia.
Pink Flags
o Daily symptoms for longer than 12 months
o Failed empiric theraphy
what are they uncertain amount causing GORD or being symptoms of GROD
o Feeding refusal
o Irritability
o Acute life threatening events
o Chest infections
name 3 ways in which you can assess GORD
- pH study/impedence
- barium swallow
- upper GI endoscopy
how do you measure pH study
– Symptom association with reflux episodes (e.g. crying babies) – pH imedence study – measure what is happening on the oesophagus at the time of the reflux episodes
how does the intraluminal impedance technique work and what is the advantage of it
- uses the technical principle
- idea too change of electrical impedance during passage of a bolus
- decrease of impedance during passage of a bolus with high conductictivity - most liquids
- they advantage of it is the idea that babies don’t have acid in the stomach to measure the reflux from therefore it is better to measure it with the intraluminal impedance technique
what does barium swallowing look for
– Anatomical abnormalities – for example such as an atresia or a malroation – can find with an x ray with a barium swallow
what does an upper GI endoscope look for
– Mucosal abnormalities – oesophagitis – most babies who have reflux do not bring up blood
What is a hiatus hernia
- this is when the stomach moves up above the diaphragm into the thoracic cavity
what is a stricture
- this is when there is narrowing in the oesophagus
how do you use a clinical score to mark GORD
- the I-GERQ-R is used
- this is a list of 12 questions that can be filled out by carers
- measures how significant refluxes are at home over the last week
what is the medical treatment of GORD
- most do not need treatment
- positioning of the infant while eating
- thickening of food
- reduce acids using H1 antagonists, proton pump inhibitors
- promotility agents such as domperidone can be used
what is the surgical treatment of GORD
- Jejunostomy feeds
- Nissen’s fundoplication. - this is when you wrap the stomach around the base of the oesophagus therefore preventing food from going back up
what is eosinophilic oesophagi’s
- this is a complication of the treatment resistant symptoms of GORD
How does eosinophilic oesophagitis present
- history of food sticky
- history of atopy
- invasion of eosinophilia
what is the treatment of eosinophilic oesophagitis
• Dietary
o Food exclusions
o Pragmatic trials.
- Oral budesonide
- Monteleukast.
what is recurrent abdominal pain
- 1 episode of pain per month for 3 months, sufficient to interfere with routine functioning
who does recurrent abdominal pain affect
- 10-15% of school children.
* F>M.
what is an abdominal migraine
paroxysmal episodes of intense pain, pain with anorexia, nausea, vomiting, headache, photophobia or pallor
how do you diagnose exclusion causes of recurrent abdominal pain
Function - over 5
- healthy
- midline, poorly localised
- am/school
- psychosocial/family problems
organic - less than 5
- other symptoms/signs
- away from the umbilicus or referred
- neonatal awakening
- IBD/ulcers
what does recurrent abdominal pain overlap with
- Migraine
- Irritable bowel syndrome
- Non ulcer dyspepsia
what is the prognosis of recurrent abdominal pain
- 50% complete resolution.
- 25% continue to adulthood.
- 25% other symptoms (e.g. headaches).
what is gastritis
– inflammation of the gastric mucosa
what can cause gastritis
- infection with Helicobacter pylori
- NSAIDs (Non-steroidal anti-inflammatories)
describe the characteristics of helicobacter pylori
o High person to person transmission
o Clustering in families
o High prevalence in lower socioeconomic classes
o Often asymptomatic
what is the symptoms of gastritis
- Vomiting
- Abdominal pain
- Haemetemesis
- Anaemia.
How do you diagnose gastritis
- Endoscopy
- Stool antigen
- C13 breath test
describe how you diagnose gastritis using endoscopy
CLO test (rapid urea test)
- inoculation of biopsy onto gel that contains urea
- the gel should change to pink as the pH rises above 6
- if H.pyori is not present then the test tube will go yellow
how does a C13 breath test work
Breath test – given a labelled urea and if there is urease present (H,pylori) then CO2 gets released and you can measure this in the breath
what is the treatment for h.pylori
- triple therapy
- use 2 antibiotics amoxycillin and clarithromycin for 2 weeks
- and a proton pump inhibitors or H2 antagonists such as laproprozole
- then repeat the stool test for HP antigen 3/12 after treatment to ensure it has gone
what are the differential diagnosis for rectal bleeding
- Constipation (with fissures/overflow diarrhoea)
- Bacterial infections (acute, with diarrhoea)
- Inflammatory bowel disease (? Diarrhoea, ? Pain)
- Polyps
- Worms
what can cause intermittent bleeding from the rectum (not seen every day in stools)
- -constiaption
- Polyps – usually ounger in toddlers and soft stools
- Worms
what can cause persistent bleeding from the rectum
- More or less every stool may also have diarrhoea
- Bacterial infections (acute, with diarrhoea)
- Inflammatory bowel diseases
what is crohns
- Mouth to anus, patchy disease “skip lesions”
- Transmural inflammation
- Granulomas
where does ulcitiis crohns tend to effect
- Only rectum/colon
- Continuous disease (starting from rectum)
- Mucosal inflammation
what is the presentation of crohns disease
• Abdominal pain • Weight loss • Diarrhoea • Insidious onset • Growth failure • Raised ESR/CRP/low albumin/Hb. - raised calprotectin greater than 20
what is the presentation of ulcitis colitis
- Chronic bloody diarrhoea
- Abdo pain
- Weight Loss
- Usually diagnosed within 2 months
paediatric onset of IBD has worse…
disease than if they are diagnosed in adults this is because it is more extensive in paediatric patients
how do you diagnose IBD
Endoscopy + Biopsies:
• Upper GI (mouth to duodenum)
• Ileo-Colonoscopy (terminal ileum to anus)
MRI Abdo:
• Previously (Ba Meal and Follow through (duodenum to ileum))
• Radiolabelled white cell scans are non-specific and have false negatives and false positives but are used in some centers
how do you induce remission in IBD
• Exclusive enteral nutrition (Chron’s)
o Reduce inflammation
o Correct undernutrition
o 6/52 of milk based formula
- Steroids
- 5-ASA
- Biologicals (e.g. anti-TNF infliximab).
How do you maintain remission in IBD
- 5-ASA (UC)
- Immunosuppressants
- Biologicals
what is a mesalamine delivery system
- this is a delivery mechanism
- – Ph dependent coat (Eudragit-S/L) dissolves Ph>7/6
– Microgranules encased ethyl cellulose coat
– Once daily dosing
what are the surgical treatments for IBD
– UC: Colectomy - curative of colitis
– Crohn’s: Depends on disease localisation, likely to need further surgery in future
when should you use surgical treatment for iBD
– Medical treatment not working
– Obstruction or other surgical emergency
– Poor growth and localised disease in Crohn’s
