Gastrointestinal/Liver Flashcards

Question

Prognosis of GOR Complications of GOR(D)

Answer 1

Posseting is very common, but 55% of infants with GOR outgrow it by 10mths and 90% by 1yr Reflux oesophagitis Oesophageal stricture (dysphagia) Barret’s oesophagus (premalignant intestinal metaphasia) FTT (growth affected in ⅔) Anaemia (chronic blood loss) Lower respiratory disease Frequent otitis media (for e.g. >6 episodes in 6mths) Dental erosion in child/young person with neurodisability (esp. CP)

Answer 2

How often does it happen, what comes up, what position are they fed in. Any signs of weightloss Diagnosis: clinical, mainly based on history of vomiting after meals Haemetemesis, melaena and dysphagia

Answer 3

When diagnosis is uncertain, poor response to treatment or if complications occur FBC (anaemia due to bleeding) Upper GI endoscopy (suspected oesophagitis) Oesophageal biopsy 24hr oesophageal pH probe (if complications occur) Barium swallow with fluoroscopy (if bile stained) Radioisotope ‘milk’ scan (aspiration) Oesophaeal manometry (oesophageal dysmotility and LOS dysfunction) CXR (assoc. respiratory disease) Congenital hiatus hernia GE Pyloric stenosis West syndrome: epileptic/ infantile spasms with abnormal brainwave patterns) UTI Non IgE-mediated cow's milk protein allergy

Answer 4

Lots and lots and lots of reassurance! It will resole by 1 year Positioning – nurse infants on head-up slope of 30° + prone Dietary Thickened milk feeds (infants) Small frequent meals – ensure parents not overfeeding baby (150ml/kg). Burping baby regularly to help milk settle. Keeping baby upright after feed Avoid food before sleep Avoid fatty foods, citrus juices, caffeine, carbonated drinks, alcohol and smoking Can use enteral tube feeding if poor weight gain but make sure to continue with oral feeds and do it for as short a time as possible

Answer 5

Drugs Gaviscon (contains antacids and an alginate that forms viscous surface layer to ↓reflux) – trial for 1-2 weeks after feeds If feeding/communication difficulties, distressed FTT or persistent pain 🡪 4 week trial of gastric acid reducing drugs – e.g. ranitidine (antacid/H2RA) or omeprazole (PPI – if oesophagitis) Last resort 🡪 prokinetic drugs – e.g. domperidone/metoclopramide or erythromycin and refer for endoscopy Mucosal protectors can also help – e.g. sucralfate Corticosteroids (if allergic oesophagitis) Surgery (rarely used)– usually Nissen’s fundoplication performed when medical Rx has failed Offer upper GI endoscopy + biopsy before deciding on fundoplication Indications: failed intense medical Rx, oesophageal stricture, Barret’s oesophagus, severe oesophagitis, recurrent apnoea, lower respiratory disease, FTT Complications of surgery: ‘gas bloating’ syndrome, dysphagia, profuse retching, ‘dumping’ syndrome

Answer 6

Not keeping down any feed (pyloric stenosis or intestinal obstruction) Projectile or forceful vomiting (pyloric stenosis or intestinal obstruction) Bile stained vomit (intestinal obstruction) Haematemesis or melaena (peptic ulcer, oesophagitis or varices) Abdominal distention (intestinal obstruction) Reduced consciousness, bulging fontanelle or neurological signs (meningitis or raised intracranial pressure) Respiratory symptoms (aspiration and infection) Blood in the stools (gastroenteritis or cows milk protein allergy) Signs of infection (pneumonia, UTI, tonsillitis, otitis or meningitis) Rash, angioedema and other signs of allergy (cows milk protein allergy) Apnoeas are a concerning feature and may indicate serious underlying pathology and need urgent assessment

Answer 7

GI infection – usually with diarrhoea Non-GI infection (e.g. UTI, meningitis, whooping cough) GI obstruction (congenital or acquired – e.g. pyloric stenosis, duodenal/ileal atresia, volvulus 🡪 congenital intestinal obstruction = bile-stained vomiting 🡪 Ix: upper GI contrast study) Overfeeding – feed >200 mL/kg per day Adverse food reaction Toxic ingestion/medications ↑ICP – effortless vomiting, neuro signs, pailloedema Endocrine/metabolic disease (e.g. DKA) ``` Chronic Peptic ulcer disease Gastro-oesophageal reflux – may lead to oesophagitis, aspiration pneumonia, apnoea and FTT Chronic infection Gastritis Gastroparesis Food allergy Psychogenic – caused by: anxiety, manipulative behaviour, disordered family dynamics (FHx of vomiting common) 🡪 exclude organic disease + refer to child psychologist Bulimia Pregnancy ``` ``` Cyclic Idiopathic CNS disease Abdominal migraine – accompanied by headache + abdo pain Endocrine (e.g. Addison’s disease) Metabolic (e.g. acute intermittent porphyria) Intermittent GI obstruction Fabricated illness ```

Answer 8

ACUTE – discrete episode of moderate-to-high intensity; MOST COMMON and usually assoc. with acute illness CHRONIC – low-grade daily pattern, frequently with mild illness CYCLIC – severe, discrete episodes assoc. with pallor, lethargy + abdominal pain. Child is well in between episodes; often FHx of migraine/vomiting ``` Dehydration Plasma electrolyte disturbance (e.g. ↓K+, ↓Cl-, alkalosis with pyloric stenosis) Acute/chronic GI bleeding (e.g. Mallory-Weiss tear) Oesophageal stricture Barret’s metaplasia Broncho-pulmonary aspiration FTT Iron deficiency anaemia ```

Answer 9

Modified socrates: early morning vomiting with CNS tumour, overfeeding, projectile vomiting (pyloric stenosis), bile-stained vomiting (intestinal obstruction), vomiting at end of cough (whooping cough), diarrhoea/blood in stools, family members with similar illness etc ENT, growth, abdo exam (palpable pyloric mass, distension), neuro exam (meningitis/↑ICP), dehydration assessment

Answer 10

ACUTE – FBC, U&E, plasma pH, Creatinine, stool culture and virology, AXR, surgical opinion if obstruction/ acute abdominal possible, exclude systemic disease CHRONIC – FBC, ESR/CRP, U&E, plasma pH, LFT, H. pylori serology, urinalysis, abdominal US, small bowel enema, sinus XR, test feed/abdominal US (pyloric stenosis), brain imaging (CNS tumour), urine pregnancy test (teenage girls), upper GI endoscopy CYCLIC – as for chronic vomiting PLUS serum amylase, lipase, ammonia and blood glucose

Answer 11

Supportive treatment oral/ IV fluids Treat cause Pharmacological Antihistamines Phenothiazines – S/Es: extrapyramidal reactions Prokinetic drugs – e.g. domperidone 5-HT3 antagonists – e.g. ondansetron 🡪 increasingly being used for Rx of post-operative/ chemotherapy-induced vomiting