Gastrointestinal I Flashcards
What is constipation in children?
Where the child delecates less than three times per week or experiences significant difficulty passing stool
What are the signs of constipation in a child?
Hard, pellet-like stool and in some cases overflow diarrhoea
How is Hirschprung’s disease diagnosed?
Rectal suction biopsy
What is the most common cause of constipation in children?
Dietary factors (low fibre diet)
How does Hirchsprung’s disease present?
- Delay in passing meconium (>48 hours)
- Distended abdomen
- Forceful evacuation of meconium after DRE
- Poor weight gain
- Poor response to movicol disimpaction regimens
How does IBS present?
- Chronic constipation
- Abdominal pain
- Bloating
- Altered bowel habit
- Pain relieved by defecation
How does hypothyroidism present in children?
- Constipation
- Weight gain
- Fatigue
- Cold intolerance
- Slow growth
How does coeliac disease present?
- Diarrhoea
- Constipation (occasionally)
- Failure to thrive
- Abdominal pain
- Bloating
How does lead poisoning present?
- Constipation
- Learning difficulties
- Irritability
- Loss of developmental skills
- Anaemia
How do anal fissures present?
Pain during and after bowel movements, occasionally leading to constipation due to fear of experiencing pain
How is functional constipation characterised?
Normal anorectal and colonic physiology but passage of hard stools, infrequent stools or painful defecation
Which neurological conditions can cause constipation?
Spina Bifida and Cerebral palsy
Impact the nerves that control bowel function, leading to constipation
What is the management of faecal impaction <1 year of age?
1st line: Lactulose 1mL/kg orally once or twice daily with dietry changes (increase fibre and hydration)
What is the management of faecal impaction >1 year of age?
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)
How should a two year old with faecal impaction who does not tolerate Movicol be treated?
Substitute Movicol for a stimulant laxative alone or in combination with an osmotic laxative such as lactulose
When should rectal medications be used for faecal disimpaction?
When all oral medications have failed
What are the rectal medications for faecal disimpaction?
1st line: sodium citrate enema
2nd line: phsophate enema (only under specialist supervision in a specialist centre)
What is the next line if oral and rectal faecal disimpaction methods have failed?
Manual evacuation of the bowel under anaesthesia
How often should children and young people undergoing disimpaction be reviewed?
Within 1 week
What is the maintenance regimen for a child with constipation?
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)
What is the policy for children who are toilet training and laxatives?
Children who are toilet training should remain on laxatives until toilet training is well established
How should laxatives be stopped in children?
Don’t stop laxatives abruptly, gradually reduce the dose over a period of months in response to stool consistency and frequency
Should idiopathic constipation be treated with dietary interventions alone?
No, should be a combination of non-punitive behavioural interventions, dietary interventions (fibre and fluid, cows’ milk exclusion) and daily physical activity
What is retentative posture?
- Straight-legged
- Tiptoed
- Back arching posture
- Straining
- Anal pain
Which medications can cause constipation?
Opiates
What is the management for faecal impaction in infants not yet weaned?
- Bottle-fed: give extra water between feeds, gental abdominal massage and bicycling the infant’s legs
- Breast-fed: organic causes should be considered
What is the managemed for faecal impaction if the infant is weaned?
- Offer extra water, diluted fruit juice and fruits
- If uneffective, consider adding lactulose
What is the pathophysiology of Hirschprung’s disease?
- Parasympathetic neuroblasts fail to migrate from the neural crest to the distal colon
- Developmental failure of the parasympathetic Auerbach and Meissner plexuses
- Uncoordinated peristalsis –> functional obstruction
What are the associations with Hirschprung’s?
- 3 times more common in males
- Down’s syndrome
Which symptoms would warrant a DRE in a child with faecal impaction?
- 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)
What is the management of Hirschsprung’s?
- Rectal washouts/ bowel irrigation
- Surgery to affected segment of colon
What is the pathophysiology of coeliac?
Sensitivity to the protein gluten leading to villous atrophy, in turn causing malabsorption
When do children normally present with coeliac?
Before the age of 3
Which genes is coeliac disease strongly associated with?
HLA-DQ2 (95% of patients), HAL-DQ8 (80% of patients)
How is coeliac disease diagnosed?
- Coeliac serology screening
- Endoscopic jejunal biopsy showing subtotal villous atrophy
What is non-responsive coeliac disease?
Persistent symptoms and enteropathy that don’t respond after 6-12 months on a self reported gluten-free diet
What is refractory coeliac disease?
Persistent or recurrent symptoms and villous atrophy on duodenal biopsy, despite strict aherence to a gluten-free diet for at least 12 months
How long should a person be gluten free before coeliac serology testing?
Minimum 6 weeks
Why are patients with coeliac disease offered the pneumococcal vaccine?
Patients with coeliac disease often have a degree of functional hyposplenism
How often should coeliac patients be given a booster for the pneumococcal vaccine?
Every 5 years
What serology should be carried out in someone suspected of coeliac?
1st line: IgA tissue transglutaminase (tTG) antibodies and total IgA
What serology should be carried out if IgA tTG is weakly positive?
IgA endomysial antibodies
What is the 2nd/3rd line serology for coeliac?
IgG EMA, IgG deamidated gliadin peptide (DGP) or IgG tTG if IgA is deficient
What are the findings of endoscopic intestinal/ jejunal biopsy that would indicate coeliac?
- Villous atrophy
- Crypt hyperplasia
- Increase in intraepithelial lymphocytes
- Lamina propria infiltration with lymphocytes
What is the management of an anal fissure?
- 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)
When should a child return to primary care with an anal fissure?
If it’s not healed within 2 weeks, then a referral to a paediatrician should be sought
When should a patient with an anal fissure always be referred to secondary care?
If it appears atypical or scarring or skin tags develop
What is the disimpaction dose of Movicol for 1-11 months?
Half a sachet daily and increase to one sachet if needed
What is the disimpaction dose of Movicol for 1-5 years?
- 2x sachets day 1
- 4x sachets days 2 and 3
- 6x sachets days 4 and 5
- 8x sachets daily
Treat until impaction resolves
What is the disimpaction dose of Movicol for 5-12 years?
- x4 sachets day 1
- Increase by x2 sachets to a max of x12 sachets daily
Treat until impaction resolves
What is the disimpaction dose of Movicol for 12-18 years?
- x4 sachets on day 1
- Increase by x2 sachets to a max of x8 sachets daily
Treat until impaction resolves
What is the maintenance dose of Movicol for 1-11 months?
1/2 sachet daily
What is the maintenance dose of Movicol for 1-6 years?
x1 sachet daily
What is the maintenance dose of Movicol for 7-11 years?
x2 sachets daily
What is the maintenance dose of Movicol for 12-18 years?
x1 sachet daily
Where is the inflammation in ulcerative colitis?
Always starts at the rectum, never spreads beyond the ileocaecal valve and is continuous
What is the peak incidence of ulcerative colitis?
15-25
Why is flexible sigmoidoscopy preferred over colonoscopy in severe ulcerative colitis?
Due to risks of potential perforation
What are the typical UC findings on flexible sigmoidoscopy?
- 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
What are the results of a barium enema for UC?
- Loss of haustrations
- Superficial ulceration, pseudopolyps
- In long standing disease, drainpipe/ lead pipe colon
Which extra intestinal features are more common in ulcerative colitis?
- Primary sclerosing cholangitis
- Uveitis
Which extra intestinal features are common in both crohn’s and ulcerative colitis?
- Arthritis (most common extra intestinal feature, pauciarticular and asymmentric)
- Erythema nodosum
- Episcleritis (more common in CD)
- Osteoporosis
- Pyoderma gangrensum
- Clubbing
What can trigger flares in UC?
- Stress
- Medications (NSAIDs/ abx)
- Cessation of smoking
What classifies a mild flare in UC?
- Fewer than 4 stools per day (+- blood)
- No systemic disturbance
- Normal ESR and CRP
What classifies a moderate flare in UC?
- 4-6 stools per day
- Minimal systemic disturbance
What classifies a severe flare in UC?
- > 6 stools per day + blood
- Systemic disturbance
How is mild-moderate ulcerative colitis with just proctitis managed to induce remission?
- 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
How is mild-moderate ulcerative colitis with proctosigmoiditis and left sided UC managed to induce remission?
- 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
What’s the management for inducing remission in mild-moderate extensive disease UC?
- 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
What is the management for inducing remission in severe colitis?
- 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
How is remission maintained in mild-moderate UC for proctitis and proctosigmoiditis?
- Topical (rectal) aminosalicylate (daily or intermittent)
Or
- Topical (rectal) aminosalicylate (daily or intermittent) + oral aminosalicylate
Or
- Oral aminosalicylate
How is remission maintained in left-sided and extensive UC?
- Low maintenance dose or oral aminosalicylate
What is the management for UC following a severe relapse or >= 2 exacerbations in the past year?
- Oral azathioprine
Or
- Oral mercaptopurine
What is not recommended for the management of UC?
Methotrexate
Which are the most common areas affected by Crohn’s?
- Terminal ileum
- Colon
But can affect anywhere from mouth to anus
Why are Crohn’s patients prone to strictures, fistulas and ahesions?
Because inflammation occurs across all layers, incuding the serosa
When does Crohn’s disease typically present?
Late adolescence or early adulthood
What are the investigation results for Crohn’s?
- Raised inflammatory markers
- Increased faecal calprotectin
- Anaemia
- Low B12 and vitamin D
- Endoscopy
What would the ileocolonoscopy results for Crohn’s show?
- Mucosal nodularity
- Erythema
- Oedema
- Ulcerations
- Granulomas
- Fistulas (if present)
- Discontinous lesions (skip lesions)
What would be seen in Crohn’s histology?
- Inflammation in all layers from mucosa to serosa
- Increased goblet cells
- Granulomas
What are the signs of Crohn’s on small bowel enema?
- Strictures: Kantor’s string sign
- Proximal bowel dilation
- Rose thorn ulcers
- Fistulae
What is the treatment regime for inducing remission in Crohn’s?
- 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
What is an alternative to azathioprine in inducing remission in Crohn’s?
Methotrexate
What is used to induce remission in refractory disease and fistulating Crohn’s?
Infliximab, patients typically continue on azathioprine or methotrexate
When is metronidazole used in Crohn’s?
For isolated peri-anal disease
What is the management for maintaining remission in Crohn’s?
- Cessation of smoking
- Azathioprine/ mercaptopurine
- Methotrexate second line
What should be assessed before starting someone on methotrexate?
- TPMT (Thiopurine S-methyltransferase) activity
What is the investigation of choice for perianal fistulae?
MRI
What is the management for symptomatic perianal fistulae?
Oral metronidazole
What are the complications of Crohn’s disease?
- Small bowel cancer
- Colorectal cancer
- Osteoporosis
What is the surgical management for UC patients who wish to avoid a stoma?
Ileoanal pouch, but this can only be offered in an elective setting
What is the safest surgical treatment option for patients with fulminant UC?
Sub total colectomy
What are the initial symptoms of necrotising enterocolitis?
- Feeding intolerance
- Abdominal distention
- Bloody stools
Can quickly progress to:
- Abdominal discolouration
- Perforation
- Peritonitis
What does an abdominal x-ray show in necrotising enterocolitis?
- 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)
At which age is appendicits most common?
10-20 years
What is the pathogenesis of appendicitis?
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
What are the most common causes of appendicitis in children?
- Lymphoid hyperplasia
- Faecolith
What is the presentation of appendicitis?
- 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
How can infants and young children present with appendicitis?
Non-specific abdominal pain and anorexia, may appear withdrawn
What worsens the pain of appendicitis?
Movement, children often report pain on coughing and not being able to hop on the right leg
What can a history of sudden relief of pain in suspected appendicitis indicate?
Appendiceal perforation
What is stump appendicitis?
Recurrent appendicitis in the remaining appendix tissue post not complete appendectomy
What signs are found on inspection and when taking observations in suspected appendicitis?
Inspection:
- Facial flushing
- Dry tongue
- Halitosis
Observations:
- Low grade fever (<38)
- Tachycardia
What signs for appendicitis are found on abdominal examination?
- 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
What may absent bowel sounds in a suspected appendicitis diagnosis indicate?
Ileus or peritonitis associated with perforation
What are the three tests for peritoneal signs associated with appendicitis?
- 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)
What are the blood and urine results in appendectomy?
- 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
What is the first line imaging for appendicitis in children?
Ultrasound scan
What is the management of appendicitis?
- Laprascopic appendicectomy
- If the diagnosis is unclear but patients are in progressive or persistent pain, explorative laparoscopy is recommended
- Administration of prophylactic IV abx
What are the post operative complications of laparoscopic appendicectomy?
- Small bowel obstruction
- Superficial wound infection
- Intra-abdominal abscess
- Stump leakage
- Stump appendicitis
What is the management of patients with appendix perforation?
Copious abdominal lavage
What is the management for appendicitis patients without peritonitis but with an appendix mass?
Broad-spectrum abx and consideration of appendicectomy
