Gastrointestinal Presentations Flashcards
PYLORIC STENOSIS ✔️ epidemiology ✔️ risk factors ✔️ clinical features ✔️ assessment / examination ✔️ appropriate investigations ✔️ management
EPIDEMIOLOGY
Most commonly occurs in infants aged 2 to 6 weeks.
RISK FACTORS ✔️ first born ✔️ male gender ✔️ Caucasian ✔️ maternal history of pyloric stenosis ✔️ recent macrolide antibiotic use
CLINICAL FEATURES
✔️ projectile vomiting immediately after meals (non-bilious)
✔️ infant irritable and hungry after vomit
✔️ initially normal bowel motions –> progressively reduced due to poor oral intake
✔️ poor growth and FTT
ASSESSMENT / EXAMINATION
✔️ weight reveals FTT on growth chart
✔️ assess hydration status
✔️ palpable pyloric mass (“olive-like”) located in the RUQ
✔️ visible “golf ball” peristalsis within the RUQ
APPROPRIATE INVESTIGATIONS
✔️ urine dipstick
✔️ blood glucose levels
✔️ FBC + WCC
✔️ UECs –> hypochloremia, hypokalaemia
✔️ VBG –> hypochloremic, hypokalaemic metabolic alkalosis
✔️ abdominal USS –> only indicated in clinical diagnosis cannot be made
MANAGEMENT
- Keep NBM
- Insert NGT
- Correct electrolyte and metabolic derangement within 24 to 48 hours
- Referral to paediatric surgery
- Ramstedt’s Pyloromyomectomy –> involves making an incision into the muscular layer of the pylorus whilst maintaining the mucosal layer
N.B. Surgery teams will not operate until metabolic alkalosis and electrolyte disturbances have been fixed, due to high risk of apnoeas.
COMPLICATIONS
✔️ apnoea (due to metabolic alkalosis)
✔️ poor growth
✔️ micronutrient deficiencies
What are the key electrolyte abnormalities associated with PYLORIC STENOSIS?
✔️ hypochloremia
✔️ hypokalaemia
✔️ hypochloremic hypokalaemic metabolic alkalosis
GASTRO OESOPHAGEAL REFLUX (DISEASE) ✔️ epidemiology ✔️ risk factors ✔️ clinical features ✔️ assessment / examination ✔️ appropriate investigations ✔️ management
EPIDEMIOLOGY
GOR begins at 8 weeks of age, peaks between 6 to 8 weeks and tends to subside by ~12 months.
RISK FACTORS
Nil. Around 40% of healthy babies experience physiological GOR many times per day.
Cow’s Milk Protein Allergy (CMPA) is a risk factor for GORD; 40% of infants with GORD have IgE CMPA.
CLINICAL FEATURES
✔️non-projectile, effortless vomiting after meals
✔️ minimal irritability
GORD may be suspected in the case of: ✔️ refusal to feed ✔️ highly irritable ✔️ aspiration ✔️ night-time cough or wheeze ✔️ poor weight gain ✔️ haematemesis
ASSESSMENT / EXAMINATION
Infants with GOR(D) will typically examine normal.
INVESTIGATIONS
Nil.
MANAGEMENT
- Encourage mother to hold baby upright for 20 to 30 minutes after feeding.
- “Burp” the baby after every meal.
- Trial smaller, more regular feeds.
- Thickened fluids (?)
- Trial elimination of cows milk from maternal diet for 2 weeks.
- Four week trial of PPI (e.g. omeprazole) if options have not alleviated symptoms.
Note that side effects of PPIs can include:
✔️ increased risk of community acquired pneumonia
✔️ osteoporosis / increased future fracture risk
✔️ gastroenteritis
✔️ micronutrient deficiencies
INTUSSUSCEPTION ✔️ epidemiology ✔️ risk factors ✔️ clinical features ✔️ assessment / examination ✔️ appropriate investigations ✔️ management
EPIDEMIOLOGY
Broad age demographic is 2 months to 2 years; most commonly involved age is 5 to 9 months.
RISK FACTORS
✔️ 90% of cases are idiopathic
✔️ 10% of cases have a “lead point” (e.g. Meckels’ Diverticulum, HSP, lymphoma)
Other risk factors include:
✔️ recent surgery
✔️ recent intussusception
✔️ recent rotavirus vaccination
CLINICAL FEATURES
✔️ intermittent, recurrent abdominal pain (increased frequency over 12 to 24 hours)
✔️ extreme irritability, crying and pallor during these episodes
✔️ child may be completely well in between
✔️ vomiting, non-bilious to begin with; bilious is a late sign
✔️ diarrhoea, “red current” jelly stained
✔️ dehydration and poor oral intake
ASSESSMENT / EXAMINATION
✔️ large palpable “sausage shaped” mass in the right quadrant which crosses the midline
✔️ abdominal distension –> bowel obstruction
✔️ guarding and rigidity –> peritonitis, perforation
✔️ red current jelly seen in stools –> bowel ischaemia
APPROPRIATE INVESTIGATIONS
- urine dipstick + MCS
- FBC + WCC
- UECs
- VBG
- Coags
- Group + Hold
- Abdo USS –> telescoping sign
MANAGEMENT
- Adequate pain relief
- Gain IV access
- Appropriate IV fluids (resuscitation, bolus, maintenance)
- Early referral to paediatric surgery
- Keep NBM
- Insert NGT if bowel obstruction suspected
- Air enema –> contraindicated if peritonitis, perforation or shock; must perform where there is a paediatric surgery team nearby for emergency / urgent laparotomy
Define CHRONIC ABDOMINAL PAIN.
Chronic abdominal pain is defined as abdominal pain that lasts > 3 months duration in a child > 3 years of age with at least 3 episodes in this period of time.
Chronic abdominal pain may be:
✔️ functional (~90% of cases)
✔️ organic (~10% of cases)
Identify organic causes of CHRONIC ABDOMINAL PAIN.
✔️ Coeliac Disease ✔️ IBD ✔️ IBS ✔️ Lactose intolerance ✔️ Chronic / severe constipation ✔️ Hepatitis ✔️ Pancreatic ✔️ Gynaecological issues (females)
N.B. Organic causes of chronic abdominal pain rarely present with abdominal pain alone. Other features of underlying disease are also present (e.g. vomiting and diarrhea, weight loss, fever).
What features distinguish organic versus functional chronic abdominal pain.
Functional abdominal pain tends to be:
✔️ non-specific / vague in characteristic and location
✔️ does not wake child at night
✔️ not associated with any food or activity
✔️ nil vomiting or diarrhoea
✔️ nil fever
✔️ psychosocial stressors may be present
What are some RED FLAG features of chronic abdominal pain?
✔️ child < 5 years of age ✔️ pain away from midline ✔️ anaemia ✔️ fever ✔️ GI blood loss ✔️ rash ✔️ pain that wakes child at night ✔️ persistent vomiting and / or diarrhoea ✔️ weight loss and / or failure to thrive ✔️ joint pain ✔️ family history of IBD
Outline differential diagnoses for ACUTE ABDOMINAL PAIN.
SURGICAL CAUSES ✔️ small bowel obstruction ✔️ intussusception ✔️ volvulus ✔️ acute appendicitis ✔️ incarnated hernia ✔️ testicular torsion ✔️ ovarian torsion / cyst ✔️ ruptured ovarian cyst
NON-SURGICAL CAUSES ✔️ gastroenteritis ✔️ mesenteric adenitis ✔️ constipation ✔️ UTI ✔️ DKA ✔️ IBD / IBS ✔️ HSP ✔️ gynaecological problems (females)
Define CONSTIPATION.
Constipation is the irregular passage of hard stools.
N.B. a child who passes one soft bowel motion every week is less likely to be constipated than a child who passes a hard, painful bowel motion every three days.
When is constipation most likely to be seen in children?
✔️ introduction of solids foods (between 6 to 9 months)
✔️ toilet training (2 to 4 years)
✔️ beginning day care / school (around 4 to 6 years)
✔️ may be precipitated by acute dehydration secondary to a viral illness
What is the diagnosis of FUNCTIONAL CONSTIPATION according to the Rome IV Criteria?
Functional constipation requires at least TWO of the following criteria to have been met in the last one month in a child > 2 years of age:
✔️ less than two bowel motions per week
✔️ passage of hard, painful stools
✔️ passage of large-diameter stools
✔️ abnormal posturing
✔️ presence of large fecal mass in the rectum
✔️ at least one incontinence episode per week (school-aged children)
Identify some organic causes of constipation (medical and surgical).
MEDICAL CAUSES ✔️ hypokalaemia ✔️ hypothyroidism ✔️ hypercalcaemia ✔️ cow's milk protein allergy ✔️ lactose intolerance ✔️ coeliac disease ✔️ IBD / IBS ✔️ neurological disorders
SURGICAL CAUSES ✔️ small bowel obstruction ✔️ volvulus ✔️ Hirchsprung's Disease ✔️ anatomical malformations of the anus ✔️ spinal cord abnormalities
Identify RED FLAGS for constipation.
✔️ child age < 6 months
✔️ delayed passage of meconium (Hirschsprung’s Disease)
✔️ ribbon-like stools (anus malformation)
✔️ weight loss / poor growth
✔️ persistent vomiting
✔️ anal mass
Outline the appropriate management of constipation including: ✔️ behavioural modification ✔️ dietary modification ✔️ oral medications ✔️ rectal medications
BEHAVIOURAL MODIFICATIONS
✔️ encourage toilet time –> sitting on the toilet for 5 to 10 minutes three times per day, 30 minutes after a meal (reward the act of sitting on the toilet, rather than the passage of a stool)
✔️ modification of position –> use a stool to make sure the child’s knees are higher than their hips; encourage leaning forward
✔️ keep a diary
✔️ reward / sticker system
✔️ delay toilet training until the child is passing relatively pain-free stools
DIETARY MODIFICATIONS
✔️ encourage a well-balanced diet, high in fruit, vegetables and whole-grains
✔️ encourage high fibre intake
✔️ avoid excessive cows’ milk consumption (<500mL per day)
✔️ encourage appropriate fluid intake
ORAL MEDICATIONS ✔️ stool softeners (e.g. Coloxyl) ✔️ osmotic laxatives (e.g. Lactulose) ✔️ iso-osmotic laxatives (e.g. Movicol) ✔️ motility agents (e.g. Senna) ✔️ lubricant (e.g. Parrafin oil)
RECTAL MEDICATIONS
✔️ rarely indicated in children
