Gastrointestinal/Liver

Question 1

What is the stepwise management of constipation in children?

Answer 1

Dietary and lifestyle modification. Stool softener (e.g. Movicol) for 2 weeks. If no responsead stimulant laxative (e.g. senna) and consider adding osmotic laxative (e.g. lactulose). If still no response, consider enema (under sedation) or manual evacuation (under GA). Once faeces have been passed at whatever stage, maintenance laxatives in the form of Movicol should be offered.

Question 2

What is the most common causative organism of gastroenteritis in children?

Answer 2

Rotavirus

Question 3

What feature of diarrhoea in gastroenteritis suggests a bacterial infection?

Answer 3

Bloody diarrhoea

Particularly campylobacter, shigella, salmonela, E.coli O157

Question 4

What investigations should be considered in a child with gastroenteritis?

Answer 4

Stool MC+S, FBC, U+Es, blood culture if worried about sepsis

Question 5

How should gastroenteritis be managed?

Answer 5

Encourage good hand hygiene. Oral rehydration solution (50 mls/kg over 4 hours) or, if severe dehydration, iv fluids. Antibiotics if septic/salmonella/C.diff. Avoid anti-diarrhoeals

Question 6

What imaging modality is most appropriate in children presenting with possible appendicitis?

Answer 6

Ultrasound abdomen

Question 7

What is the conservative approach to managing simple gastro-oesophageal reflux in babies?

Answer 7

Reassure, monitor growth. Thicken feeds to help milk stay down. Avoid overfeeding, smaller but more frequent feeds are better. Position upright for 30 mins after feeds.

Question 8

What features help to differentiate mesenteric adenitis from appendicitis?

Answer 8

Mesenteric adenitis is usually the result of an intercurrent viral infection. Usually no guarding or peritonism.

Question 9

What does bile stained vomit indicate?

Answer 9

Intestinal obstruction

Question 10

What is the most likely cause of non-bilious, projectile vomiting in the first few weeks of life?

Answer 10

Pyloric stenosis

Question 11

How may Hirschprung’s disease present?

Answer 11

Failure to pass meconium in first 24 hours of life. Abdominal distension and later bile-stained vomit develop. Some may present with life-threatening Hirschprung’s enterocolitis during first few weeks of life due to C. diff infection. FTT.
In later childhood, chronic constipation with profound abdo distension.

Question 12

How is Hirschprung’s disease definitively diagnosed?

Answer 12

Suction rectal biopsy showing absence of ganglion cells and presence of thickened non-myelinated nerves; increased activity of acetylcholinesterase

Question 13

What genes are linked to Coeliac disease?

Answer 13

HLA-DQ2 and HLA-DQ8

Question 14

Which patient groups have an increased risk of coeliac disease?

Answer 14

T1DM, autoimmune thyroid disease, Down’s syndrome. Positive family history.

Question 15

Which highly sensitive and specific serological tests are used to aid diagnosis of coeliac disease

Answer 15

IgA tissue transaminase antibodies and endomysial antibodies

Question 16

How is coeliac disease definitively diagnosed?

Answer 16

Endoscopic small intestinal biopsy showing mucosal changes (raised intraepithelial lymphocytes, villous atrophy, crypt hypertrophy) followed by resolution of symptoms upon withdrawal of gluten

Question 17

How can you differentiate between an inguinal hernia and a hydrocele?

Answer 17

Can get above a hydrocele, can’t get above an inguinal hernia. Also a hydrocele, transilluminates.

Question 18

Where does intussusception most frequently occur?

Answer 18

The ileum passing through into the caecum through the ileocaecal valve.

Question 19

How may intussusception present?

Answer 19

Sausage-shaped mass, red-currant jelly stool, spasmodic abdominal pain. Child usually well between the painful periods.

Question 20

What often forms the pathological and non-pathological lead points in intussusception?

Answer 20

Non-pathological (younger kids): Enlarged Peyer’s patch - often following viral infection
Pathological (older kids): Meckel’s diverticulum or polyp

Question 21

What is sign is classically seen on US in intussusception?

Answer 21

Target sign - showing invagination of proximal bowel into distal bowel

Question 22

How is intussusception managed?

Answer 22

Urgent surgical referral. NBM. Drip and suck (NG tube to decompress the bowel and fluids).
If < 24 hours since onset: air enema to correct
If > 24 hours since onset or very sick child: surgery as enema may cause perforation

Question 23

What is seen on ABG/VBG in pyloric stenosis?

Answer 23

Hypochloraemic, hypokalaemic, hyponatraemic metabolic alkalosis

Question 24

In what relatively common neonatal condition may you see visible gastric peristalsis?

Answer 24

Pyloric stenosis

Question 25

How is pyloric stenosis definitively managed?

Answer 25

Pyloromyomectomy

Question 26

How is testicular torsion managed?

Answer 26

Immediate surgical exploration. Salvage the testis and fix both to prevent recurrence. If the teste is necrosed, remove it.

Question 27

What risks are associated with undescended testes?

Answer 27

Risk of malignancy. Bilateral undescended testes reduce fertility by about 50%.

Question 28

How is undescended testes managed?

Answer 28

If no spontaneous descent by 6 months - 1 year, perform orchidopexy via inguinal incision.

Question 29

How may biliary atresia present?

Answer 29

Usually mild (conjugated) jaundice that is prolonged. Pale stools, dark urine. FTT. May be hepatomegaly.

Question 30

How is biliary atresia diagnosed?

Answer 30

Diagnosis confirmed at laparotomy with operative cholangiography which fails to outline a normal biliary tree.

Question 31

What is the name of the procedure that is used to manage biliary atresia?

Answer 31

Kasai procedure (surgical bypass of fibrotic ducts using a loop of jejunum).

Question 32

With regards to hepatitis B serology, what does positive anti-HBc antibodies indicate?

Answer 32

Acute infection

Question 33

With regards to hepatitis B serology, what does positive HBsAg indicate?

Answer 33

Ongoing infectivity

Question 34

What is the classical description of diarrhoea in Toddler’s diarrhoea?

Answer 34

Often said to have undigested food in it

“peas and carrots diarrhoea”

Question 35

How may volvulus present?

Answer 35

Obstruction +/- ischaemic bowel. Bilious vomiting usual present in first few days of life but can be later. Abdo tenderness.

Question 36

What signs may be seen on AXR in volvulus?

Answer 36

Coffee-bean sign indicating sigmoid volvulus

Double-bubble sign indicating high small bowel obstruction

Question 37

What is the standard diagnostic test for intestinal malrotation (including volvulus)?

Answer 37

Upper GI contrast study

Question 38

How is volvulus managed?

Answer 38

Urgent laparotomy to untwist volvulus and mobilise duodenum.