GI Flashcards
What is gastro-oesophageal reflux and how does it differ from GORD?
Passage of gastric contents into the oesophagus - can be normal in infants if asymptomatic
GORD involves the presence of symptoms or complications from the reflux
Why are infants predisposed to GORD?
- Short, narrow oesophagus
- Delayed gastric emptying
- Shorter, lower sphincter
- Liquid diet
- Larger ratio of gastric volume to oesophageal volume
What are some risk factors for GORD in infants?
Prematurity, hiatus hernia, history of diaphragmatic hernia or oesophageal atresia, family history of reflux
What are the clinical features of GORD?
Distressed behaviour eg excessive crying, back-arching
Unexplained feeding difficulties eg refusing feeds, gagging, choking
Faltering growth
Hoarseness/chronic cough in children
What are the differentials of GORD?
Pyloric stenosis, intestinal obstruction, sepsis, UTI, gastroenteritis
What is the management of GORD?
Ensure infant is not overfed (no more than 150ml/kg/day)
Decrease feed volume by increasing frequency eg 2-3 hourly
Gaviscon
Omeprazole, ranitidine
What is coeliac disease?
A life long gluten sensitive autoimmune disease of the small intestine
What environmental and genetic factors are implicated in coeliac disease?
Gliadin and HLA-DQ2/DQ8
Explain the pathophysiology of coeliac disease
T cell mediated immune disorder
Anti-gluten CD4 T cell response - anti-gluten antibodies - autoantibodies against tissue transglutaminase endomysium and activation of intraepithelial lymphocytes
Leads to epithelial cell destruction and villous atrophy
What conditions are related to coeliac disease?
Type 1 diabetes, Down syndrome, Turner syndrome, autoimmune thyroid disease, rheumatoid arthritis and Addison’s disease
How does the classical form of coeliac disease present?
Most commonly at 9-24 months of age with features of malabsorption - failure to thrive, weight loss, loose stool, steatorrhoea, anorexia, abdominal pain
What does histology show in coeliac disease?
Crypt hyperplasia and villous atrophy
What extra intestinal features can be seen in coeliac disease?
Dermatitis herpetiformis, dental enamel hypoplasia, osteoporosis, delayed puberty, short stature, iron deficiency anaemia, arthritis, peripheral neuropathy
How is coeliac disease investigated?
IgA and IgA tissue transflutaminase
Can also used IgA endomysial antibodies
Duodenal biopsy
How do you ensure that investigations for coeliac disease are accurate?
Will only be accurate if the patient is having gluten in the diet at the time of testing and for at least 6 weeks before
What is cow’s milk protein allergy?
An immune-mediated allergic response to naturally occurring milk proteins casein and whey
What are the two types of cow’s milk protein allergy?
IgE mediated - type 1 hypersensitivity reaction where CD4+ TH2 cells stimulate B cells to produce IgE antibodies against cow’s milk protein which trigger the release of histamine and other cytokines from mast cells and basophils
Non-IgE mediated - involves T cell activation against cow’s milk protein
What are some risk factors for cow’s milk protein allergy?
Personal history of atopy
Family history of atopy
What are the clinical features of IgE-mediated cow’s milk protein allergy?
Acute onset (up to 2 hours after ingestion)
Pruritus Urticaria Angio-oedema Oral pruritus Nausea + vomiting Colicky abdominal pain Cough, chest tightness, wheezing Sneezing, rhinorrhoea
What are the clinical features of non IgE-mediated cow’s milk protein allergy?
Non-acute and generally delayed onset (manifest up to 48 hours or even 1 week after ingestion)
GORD, blood/mucus in stools, abdominal pain, infantile colic, food refusal, constipation, faltering growth, some resp symptoms
What are some differentials of cow’s milk protein allergy?
Food intolerance, allergic reaction to other allergens, Meckel’s diverticulum, GORD, coeliac, IBD, pancreatic insufficiency, UTI
How is cow’s milk protein allergy managed?
Avoidance of cow’s milk
Extensively hydrolysed formula - casein and whey are broken down into smaller peptides
Amino acid formula
What are some viral causes of gastroenteritis in children?
Rotavirus, norovirus, adenovirus
When is the rotavirus oral vaccine given?
At 8 and 12 weeks
What are some bacterial causes of gastroenteritis?
Campylobacter (can cause bloody diarrhoea) and E-coli
What life threatening complications can verocytotoxin producing E-coli have?
Haemorrhage colitis and haemolytic uraemia syndrome
What are the paediatric fluid requirements?
0-10kg = 100ml/kg/day
10-20kg = requirement for the 1st 10kg (1000ml) + 50ml/kg/day
> 20kg = requirement for the 1st 20kg (1500ml) + 20ml/kg/day
What is Reiter’s syndrome?
Urethritis, arthritis and uveitis
What are reactive complications associated with bacterial gastroenteritis?
Arthritis, carditis, urticaria, erythema nodosum and conjunctivitis
What is a rare but significant complication of rotavirus gastroenteritis?
Toxic megacolon
Which part of the digestive tract does Crohn’s commonly target?
Distal ileum or proximal colon
What are some pathological features of Crohn’s disease?
Transmural inflammation producing deep ulcer and fissures (cobblestone)
Skip lesions
Non-caseating granulomatous inflammation
Can form fistulas
What are some clinical features of Crohn’s disease?
Episodic abdominal pain and diarrhoea which may contain blood/mucus
Malaise, anorexia, low grade fever
Oral aphthous ulcers and perianal disease
What are some extra intestinal features of IBD?
Enteropathic arthritis, erythema nodosum, pyoderma gangrenosum, episcleritis, anterior uveitis
How is Crohn’s investigated?
Routine bloods, CRP, faecal calprotectin, stool sample, colonoscopy with biopsy, CT scan abdomen pelvis, MRI scan
How is Crohn’s managed?
Inducing remission - fluid resuscitation, nutritional support, corticosteroid and immunosuppressive drugs (eg mesalazine)
Maintaining remission - azathioprine/mesalazine, biological agents eg infliximab
Surgical management - ileocaecal resection
What is ulcerative colitis characterised by?
Diffuse continual mucosal inflammation of the large bowel, beginning in the rectum and spreading proximally
What are some pathological features of ulcerative colitis?
Inflammation of the mucosa and submucosa, crypt abscesses and goblet cell hypoplasia
What are the clinical features of ulcerative colitis?
Bloody diarrhoea, mucus discharge, increased frequency, urgency of defecation and tenesmus
What are some red flags in a child with constipation?
Delay in passing meconium for more than 48 hours after birth
Family history of Hirschsprung’s
Ribbon stool pattern
Leg weakness or motor delay
Abnormal appearance of the anus
Evidence of faltering growth/developmental delay
What behavioural interventions can be suggested for a child with constipation?
Scheduled toileting (encouraging to open bowels at pre-planned intervals or activities)
Bowel habit diary
Encouragement and rewards systems
