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Paediatrics > Gastrointestinal I > Flashcards

Gastrointestinal I Flashcards

1
Q

What is constipation in children?

A

Where the child delecates less than three times per week or experiences significant difficulty passing stool

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2
Q

What are the signs of constipation in a child?

A

Hard, pellet-like stool and in some cases overflow diarrhoea

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3
Q

How is Hirschprung’s disease diagnosed?

A

Rectal suction biopsy

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4
Q

What is the most common cause of constipation in children?

A

Dietary factors (low fibre diet)

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5
Q

How does Hirchsprung’s disease present?

A
  • Delay in passing meconium (>48 hours)
  • Distended abdomen
  • Forceful evacuation of meconium after DRE
  • Poor weight gain
  • Poor response to movicol disimpaction regimens
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6
Q

How does IBS present?

A
  • Chronic constipation
  • Abdominal pain
  • Bloating
  • Altered bowel habit
  • Pain relieved by defecation
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7
Q

How does hypothyroidism present in children?

A
  • Constipation
  • Weight gain
  • Fatigue
  • Cold intolerance
  • Slow growth
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8
Q

How does coeliac disease present?

A
  • Diarrhoea
  • Constipation (occasionally)
  • Failure to thrive
  • Abdominal pain
  • Bloating
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9
Q

How does lead poisoning present?

A
  • Constipation
  • Learning difficulties
  • Irritability
  • Loss of developmental skills
  • Anaemia
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10
Q

How do anal fissures present?

A

Pain during and after bowel movements, occasionally leading to constipation due to fear of experiencing pain

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11
Q

How is functional constipation characterised?

A

Normal anorectal and colonic physiology but passage of hard stools, infrequent stools or painful defecation

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12
Q

Which neurological conditions can cause constipation?

A

Spina Bifida and Cerebral palsy

Impact the nerves that control bowel function, leading to constipation

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13
Q

What is the management of faecal impaction <1 year of age?

A

1st line: Lactulose 1mL/kg orally once or twice daily with dietry changes (increase fibre and hydration)

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14
Q

What is the management of faecal impaction >1 year of age?

A

1st line: osmotic laxative (polyethylene glycol (PEG) 3350 electrolytes aka Movicol), this can be mixed with a cold drink

If impaction not achieved in 2 weeks, add a stimulant laxative eg. Senna (>2y/o), Bisacodyl (>12y/o), Sodium picosulfate (>4y/o)

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15
Q

How should a two year old with faecal impaction who does not tolerate Movicol be treated?

A

Substitute Movicol for a stimulant laxative alone or in combination with an osmotic laxative such as lactulose

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16
Q

When should rectal medications be used for faecal disimpaction?

A

When all oral medications have failed

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17
Q

What are the rectal medications for faecal disimpaction?

A

1st line: sodium citrate enema
2nd line: phsophate enema (only under specialist supervision in a specialist centre)

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18
Q

What is the next line if oral and rectal faecal disimpaction methods have failed?

A

Manual evacuation of the bowel under anaesthesia

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19
Q

How often should children and young people undergoing disimpaction be reviewed?

A

Within 1 week

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20
Q

What is the maintenance regimen for a child with constipation?

A

Following disimpaction therapy:

1st line: Polyethylene glycol 3350 + electrolites and adjust the dose according to symptoms and response

(add a stimulant laxative if this doesn’t work, substitute a stimulant laxative alone or lactulose if movicol not tolerated)

Continue medication at maintenance dose for several weeks after regular bowel habit is established (can take several months)

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21
Q

What is the policy for children who are toilet training and laxatives?

A

Children who are toilet training should remain on laxatives until toilet training is well established

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22
Q

How should laxatives be stopped in children?

A

Don’t stop laxatives abruptly, gradually reduce the dose over a period of months in response to stool consistency and frequency

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23
Q

Should idiopathic constipation be treated with dietary interventions alone?

A

No, should be a combination of non-punitive behavioural interventions, dietary interventions (fibre and fluid, cows’ milk exclusion) and daily physical activity

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24
Q

What is retentative posture?

A
  • Straight-legged
  • Tiptoed
  • Back arching posture
  • Straining
  • Anal pain
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25
Q

Which medications can cause constipation?

A

Opiates

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26
Q

What is the management for faecal impaction in infants not yet weaned?

A
  • Bottle-fed: give extra water between feeds, gental abdominal massage and bicycling the infant’s legs
  • Breast-fed: organic causes should be considered
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27
Q

What is the managemed for faecal impaction if the infant is weaned?

A
  • Offer extra water, diluted fruit juice and fruits
  • If uneffective, consider adding lactulose
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28
Q

What is the pathophysiology of Hirschprung’s disease?

A
  1. Parasympathetic neuroblasts fail to migrate from the neural crest to the distal colon
  2. Developmental failure of the parasympathetic Auerbach and Meissner plexuses
  3. Uncoordinated peristalsis –> functional obstruction
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29
Q

What are the associations with Hirschprung’s?

A
  • 3 times more common in males
  • Down’s syndrome
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30
Q

Which symptoms would warrant a DRE in a child with faecal impaction?

A
  • Delayed passage of meconium (>48 hrs)
  • Constipation since first few weeks of life
  • Chronic abdominal distention (+ vomiting)
  • Family hx of Hirschsprung’s
  • Faltering growth (in addition to any of the previous features)
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31
Q

What is the management of Hirschsprung’s?

A
  • Rectal washouts/ bowel irrigation
  • Surgery to affected segment of colon
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32
Q

What is the pathophysiology of coeliac?

A

Sensitivity to the protein gluten leading to villous atrophy, in turn causing malabsorption

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33
Q

When do children normally present with coeliac?

A

Before the age of 3

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34
Q

Which genes is coeliac disease strongly associated with?

A

HLA-DQ2 (95% of patients), HAL-DQ8 (80% of patients)

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35
Q

How is coeliac disease diagnosed?

A
  1. Coeliac serology screening
  2. Endoscopic jejunal biopsy showing subtotal villous atrophy
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36
Q

What is non-responsive coeliac disease?

A

Persistent symptoms and enteropathy that don’t respond after 6-12 months on a self reported gluten-free diet

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37
Q

What is refractory coeliac disease?

A

Persistent or recurrent symptoms and villous atrophy on duodenal biopsy, despite strict aherence to a gluten-free diet for at least 12 months

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38
Q

How long should a person be gluten free before coeliac serology testing?

A

Minimum 6 weeks

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39
Q

Why are patients with coeliac disease offered the pneumococcal vaccine?

A

Patients with coeliac disease often have a degree of functional hyposplenism

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40
Q

How often should coeliac patients be given a booster for the pneumococcal vaccine?

A

Every 5 years

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41
Q

What serology should be carried out in someone suspected of coeliac?

A

1st line: IgA tissue transglutaminase (tTG) antibodies and total IgA

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42
Q

What serology should be carried out if IgA tTG is weakly positive?

A

IgA endomysial antibodies

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43
Q

What is the 2nd/3rd line serology for coeliac?

A

IgG EMA, IgG deamidated gliadin peptide (DGP) or IgG tTG if IgA is deficient

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44
Q

What are the findings of endoscopic intestinal/ jejunal biopsy that would indicate coeliac?

A
  • Villous atrophy
  • Crypt hyperplasia
  • Increase in intraepithelial lymphocytes
  • Lamina propria infiltration with lymphocytes
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45
Q

What is the management of an anal fissure?

A
  • If caused by constipation, manage the constipation
  • If not constipated, give dietary advice (fibre, fluid intake)

Give lifestyle advice for healing the fissure:
- Correct anal hygiene (clean and dry)
- Advise against stool witholding and straining

Manage pain:
- Simple analgesia (paracetamol/ ibuprofen)
- Sit in a shallow, warm bath several times a day (particularly after a stool movement)

46
Q

When should a child return to primary care with an anal fissure?

A

If it’s not healed within 2 weeks, then a referral to a paediatrician should be sought

47
Q

When should a patient with an anal fissure always be referred to secondary care?

A

If it appears atypical or scarring or skin tags develop

48
Q

What is the disimpaction dose of Movicol for 1-11 months?

A

Half a sachet daily and increase to one sachet if needed

49
Q

What is the disimpaction dose of Movicol for 1-5 years?

A
  • 2x sachets day 1
  • 4x sachets days 2 and 3
  • 6x sachets days 4 and 5
  • 8x sachets daily

Treat until impaction resolves

50
Q

What is the disimpaction dose of Movicol for 5-12 years?

A
  • x4 sachets day 1
  • Increase by x2 sachets to a max of x12 sachets daily

Treat until impaction resolves

51
Q

What is the disimpaction dose of Movicol for 12-18 years?

A
  • x4 sachets on day 1
  • Increase by x2 sachets to a max of x8 sachets daily

Treat until impaction resolves

52
Q

What is the maintenance dose of Movicol for 1-11 months?

A

1/2 sachet daily

53
Q

What is the maintenance dose of Movicol for 1-6 years?

A

x1 sachet daily

54
Q

What is the maintenance dose of Movicol for 7-11 years?

A

x2 sachets daily

55
Q

What is the maintenance dose of Movicol for 12-18 years?

A

x1 sachet daily

56
Q

Where is the inflammation in ulcerative colitis?

A

Always starts at the rectum, never spreads beyond the ileocaecal valve and is continuous

57
Q

What is the peak incidence of ulcerative colitis?

A

15-25

58
Q

Why is flexible sigmoidoscopy preferred over colonoscopy in severe ulcerative colitis?

A

Due to risks of potential perforation

59
Q

What are the typical UC findings on flexible sigmoidoscopy?

A
  • Red, raw mucosa that bleeds easily
  • No inflammation beyond the submucosa
  • Ulceration with preservation of adjacent mucosa (forming pseudopolyps)
  • Inflammatory cell infiltrate in the lamina propria
  • Crypt abscesses (neutrophils migrate through walls of glands)
  • Depletion of goblet cells and mucin
60
Q

What are the results of a barium enema for UC?

A
  • Loss of haustrations
  • Superficial ulceration, pseudopolyps
  • In long standing disease, drainpipe/ lead pipe colon
61
Q

Which extra intestinal features are more common in ulcerative colitis?

A
  • Primary sclerosing cholangitis
  • Uveitis
62
Q

Which extra intestinal features are common in both crohn’s and ulcerative colitis?

A
  • Arthritis (most common extra intestinal feature, pauciarticular and asymmentric)
  • Erythema nodosum
  • Episcleritis (more common in CD)
  • Osteoporosis
  • Pyoderma gangrensum
  • Clubbing
63
Q

What can trigger flares in UC?

A
  • Stress
  • Medications (NSAIDs/ abx)
  • Cessation of smoking
64
Q

What classifies a mild flare in UC?

A
  • Fewer than 4 stools per day (+- blood)
  • No systemic disturbance
  • Normal ESR and CRP
65
Q

What classifies a moderate flare in UC?

A
  • 4-6 stools per day
  • Minimal systemic disturbance
66
Q

What classifies a severe flare in UC?

A
  • > 6 stools per day + blood
  • Systemic disturbance
67
Q

How is mild-moderate ulcerative colitis with just proctitis managed to induce remission?

A
  • Topical (rectal) aminoslaicylate (eg. mesalazine)
  • If remission not achieved within 4 weeks, add oral aminosalicylate
  • If remission still not achieved, add topical or oral corticosteroid
68
Q

How is mild-moderate ulcerative colitis with proctosigmoiditis and left sided UC managed to induce remission?

A
  • Topical (rectal) aminosalicylate
  • If remission not achieved within 4 weeks, add high-dose oral aminosalicylate or switch to high-dose oral aminosalicylate and topical corticosteroid
  • If remission still not achieved, stop topical treatments and offer oral aminosalicylate and oral corticosteroid
69
Q

What’s the management for inducing remission in mild-moderate extensive disease UC?

A
  • Topical (rectal) aminosalicylate and a high-dose oral aminosalicylate
  • If remission not achieved at 4 weeks, stop topical treatments and offer high-dose oral aminosalicylate and oral corticosteroid
70
Q

What is the management for inducing remission in severe colitis?

A
  • Treated as an in patient in hospital
  • IV steroids (IV ciclosporin if steroids are contraindicated)
  • No improvement after 72 hours, consider adding IV ciclosporin to IV corticosteroids, or consider surgery
71
Q

How is remission maintained in mild-moderate UC for proctitis and proctosigmoiditis?

A
  • Topical (rectal) aminosalicylate (daily or intermittent)

Or

  • Topical (rectal) aminosalicylate (daily or intermittent) + oral aminosalicylate

Or

  • Oral aminosalicylate
72
Q

How is remission maintained in left-sided and extensive UC?

A
  • Low maintenance dose or oral aminosalicylate
73
Q

What is the management for UC following a severe relapse or >= 2 exacerbations in the past year?

A
  • Oral azathioprine

Or

  • Oral mercaptopurine
74
Q

What is not recommended for the management of UC?

A

Methotrexate

75
Q

Which are the most common areas affected by Crohn’s?

A
  • Terminal ileum
  • Colon

But can affect anywhere from mouth to anus

76
Q

Why are Crohn’s patients prone to strictures, fistulas and ahesions?

A

Because inflammation occurs across all layers, incuding the serosa

77
Q

When does Crohn’s disease typically present?

A

Late adolescence or early adulthood

78
Q

What are the investigation results for Crohn’s?

A
  • Raised inflammatory markers
  • Increased faecal calprotectin
  • Anaemia
  • Low B12 and vitamin D
  • Endoscopy
79
Q

What would the ileocolonoscopy results for Crohn’s show?

A
  • Mucosal nodularity
  • Erythema
  • Oedema
  • Ulcerations
  • Granulomas
  • Fistulas (if present)
  • Discontinous lesions (skip lesions)
80
Q

What would be seen in Crohn’s histology?

A
  • Inflammation in all layers from mucosa to serosa
  • Increased goblet cells
  • Granulomas
81
Q

What are the signs of Crohn’s on small bowel enema?

A
  • Strictures: Kantor’s string sign
  • Proximal bowel dilation
  • Rose thorn ulcers
  • Fistulae
82
Q

What is the treatment regime for inducing remission in Crohn’s?

A
  • Glucocorticoids (oral, topical or IV)
  • Enteral feeding
  • 5-ASA drugs (eg. mesalazine), second line to glucocorticoids
  • Azathioprine/ metacaptopurine can be used as adjunct but not monotherapy
83
Q

What is an alternative to azathioprine in inducing remission in Crohn’s?

A

Methotrexate

84
Q

What is used to induce remission in refractory disease and fistulating Crohn’s?

A

Infliximab, patients typically continue on azathioprine or methotrexate

85
Q

When is metronidazole used in Crohn’s?

A

For isolated peri-anal disease

86
Q

What is the management for maintaining remission in Crohn’s?

A
  • Cessation of smoking
  • Azathioprine/ mercaptopurine
  • Methotrexate second line
87
Q

What should be assessed before starting someone on methotrexate?

A
  • TPMT (Thiopurine S-methyltransferase) activity
88
Q

What is the investigation of choice for perianal fistulae?

A

MRI

89
Q

What is the management for symptomatic perianal fistulae?

A

Oral metronidazole

90
Q

What are the complications of Crohn’s disease?

A
  • Small bowel cancer
  • Colorectal cancer
  • Osteoporosis
91
Q

What is the surgical management for UC patients who wish to avoid a stoma?

A

Ileoanal pouch, but this can only be offered in an elective setting

92
Q

What is the safest surgical treatment option for patients with fulminant UC?

A

Sub total colectomy

93
Q

What are the initial symptoms of necrotising enterocolitis?

A
  • Feeding intolerance
  • Abdominal distention
  • Bloody stools

Can quickly progress to:
- Abdominal discolouration
- Perforation
- Peritonitis

94
Q

What does an abdominal x-ray show in necrotising enterocolitis?

A
  • Dilated bowel loops (often asymmetrical)
  • Bowel wall oedema
  • Pneumatosis intestinalis (intramural gas)
  • Portal venous gas
  • Pneumoperitoneum resulting from perforation
  • Air inside and outside the bowel wall (Rigler sign)
  • Air outlining the falciform ligament (football sign)
95
Q

At which age is appendicits most common?

A

10-20 years

96
Q

What is the pathogenesis of appendicitis?

A

Obstruction of the intestinal lumen –> gut organisms invading the appendix wall –> oedema, ischaemia +- perforation

Initial inflammation compresses afferent visceral nerves leading to referred peri-umbilical pain, as the appendix increases in size it presses on the abdominal wall, causing pain to migrate to the right lower quadrant

97
Q

What are the most common causes of appendicitis in children?

A
  • Lymphoid hyperplasia
  • Faecolith
98
Q

What is the presentation of appendicitis?

A
  • Periumbilical/ epigastric pain migrating to the RLQ over 24-48 hours
  • Low grade fever
  • Nausea/ vomiting
  • Constipation (diarrhoea is rare but can occur due to localised rectal irritation or pelvic abscess formation)
  • Anorexia
99
Q

How can infants and young children present with appendicitis?

A

Non-specific abdominal pain and anorexia, may appear withdrawn

100
Q

What worsens the pain of appendicitis?

A

Movement, children often report pain on coughing and not being able to hop on the right leg

101
Q

What can a history of sudden relief of pain in suspected appendicitis indicate?

A

Appendiceal perforation

102
Q

What is stump appendicitis?

A

Recurrent appendicitis in the remaining appendix tissue post not complete appendectomy

103
Q

What signs are found on inspection and when taking observations in suspected appendicitis?

A

Inspection:
- Facial flushing
- Dry tongue
- Halitosis

Observations:
- Low grade fever (<38)
- Tachycardia

104
Q

What signs for appendicitis are found on abdominal examination?

A
  • Tenderness over McBurney’s point
  • Abdominal distention
  • Guarding
  • Rebound tenderness
  • Palpable abdominal mass (appendix mass or abscess)
  • If DRE is performed, pelvic abscess will cause boggy sensation and pelvic appendix may cause right sided pain to be elicited
105
Q

What may absent bowel sounds in a suspected appendicitis diagnosis indicate?

A

Ileus or peritonitis associated with perforation

106
Q

What are the three tests for peritoneal signs associated with appendicitis?

A
  • Rovsing’s sign - palpation of LLQ increases pain in RLQ (bowel contents pushed towards appendix)
  • Psoas sign - passive extension of right thigh in left lateral position elicits pain in RLQ (friction between psoas muscle and appendix)
  • Obturator sign - passive internal rotation of flexed right thigh elicits pain in RLQ (friction between obturator muscle and appendix)
107
Q

What are the blood and urine results in appendectomy?

A
  • FBC: neutrophil predominant leucocytosis
  • CRP: may be normal or raised
  • Urine dip: 40% of patients will have urinary leukocytosis due to close proximity of appendix to urinary tract, but no nitrites should be seen
  • Pregnancy test in females of childbearing age to exclude ectopic pregnancy
108
Q

What is the first line imaging for appendicitis in children?

A

Ultrasound scan

109
Q

What is the management of appendicitis?

A
  • Laprascopic appendicectomy
  • If the diagnosis is unclear but patients are in progressive or persistent pain, explorative laparoscopy is recommended
  • Administration of prophylactic IV abx
110
Q

What are the post operative complications of laparoscopic appendicectomy?

A
  • Small bowel obstruction
  • Superficial wound infection
  • Intra-abdominal abscess
  • Stump leakage
  • Stump appendicitis
111
Q

What is the management of patients with appendix perforation?

A

Copious abdominal lavage

112
Q

What is the management for appendicitis patients without peritonitis but with an appendix mass?

A

Broad-spectrum abx and consideration of appendicectomy

Paediatrics (16 decks)

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