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Paediatrics > GI > Flashcards

GI Flashcards

1
Q

How does appendicitis present?

A
  • central abdo pain which then moves to the right iliac fossa
  • tenderness in McBurney’s point (1/3rd the distance from the ASIS to umbilicus)
  • loss of appetitie
  • Rovsing’s sign (palpation of LIF causes RIF pain)
  • guarding
  • rebound tenderness - (suggesting peritonitis and rupture)
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2
Q

How is appendicitis diagnosed?

A
  • clinical presentation
  • bloods - show raised inflammatory markers
  • CT or ultrasound scan (can exclude gynae causes)
  • diagnostic laparoscopy
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3
Q

Differentials for appendicitis

A
  • ectopic pregnancy
  • ovarian cysts (rupture or torsion)
  • Meckel’s Diverticulum
  • mesenteric adenitis
  • appendix mass
    + many more (e.g. renal stones, testicular torsion)
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4
Q

How is appendicitis managed?

A

appendicectomy - normally laparoscopic

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5
Q

What are the complications of appendicectomy?

A
  • bleeding, infection, pain
  • damage to bowel, bladder or other organs
  • anaesthetic risks
  • VTE
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6
Q

What are some medical causes of abdominal pain in children?

A
  • constipation
  • UTI / pyelonephritis
  • gastroenteritis
  • IBS /IBD
  • coeliacs
  • mesenteric adenitis
  • abdominal migrane
  • henoch-schonlein purpura
  • DKA
  • infantile colic
  • (non organic / functional pain)

In girls
- dysmenorrhea
- mittelschmerz (ovulation pain)
- ectopic
- PID
- ovarian torsion
- pregnancy

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7
Q

What are some surgical causes of abdominal pain in children?

A
  • appendicitis
  • intestinal obstruction
  • intussusception
  • testicular torsion
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8
Q

What are red flags associated with abdominal pain in children?

A
  • blood in stools / rectal bleeding
  • bilious or persistent vomiting
  • severe chronic diarrhoea
  • fever
  • weight loss / slowed growth
  • dysphagia (difficulty swallowing)
  • nighttime pain
  • abdominal tenderness
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9
Q

What is recurrent abdominal pain?

A

When there are repeated episodes of abdominal pain without an identifiable underlying cause.

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10
Q

What is the theory behind recurrent abdominal pain?

A

Increased sensitivity and inappropriate pain signals from the visceral nerves in the gut in response to normal stimuli. Often happens around stressful life events.

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11
Q

How is recurrent abdominal pain managed?

A
  • careful explanation and reassurance
  • distraction techniques
  • encourage not to focus on the pain
  • lifestyle advice - regular meals, balanced diet, exercise, stay hydrated, reduce stress
  • probiotics may helps
  • avoid NSAIDs - e.g. iBuprofen
  • address psychosocial triggers - e.g. support with school counsellor or child psychologist
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12
Q

What is an abdominal migrane?

A
  • central abdominal pain lasting more than 1 hour
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13
Q

What symptoms may be associated with an abdominal migrane?

A
  • central abdo pain >1hr
  • nausea and vomiting
  • anorexia
  • pallor
  • headache
  • photophobia
  • aura
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14
Q

How are abdominal migranes managed acutely?

A
  • low stimuli environment - quiet, dark room
  • painkillers - paracetamol and ibuprofen or sumatriptan
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15
Q

How are abdominal migranes prevented?

A
  • Pizotifen - serotonic agonist. (This needs to be withdrawn slowly when stopping to reduce symptoms of depression, anxiety, poor sleep and tremor.)

Other options include
- propanolol

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16
Q

What is pyloric stenosis?

A

Hypertrophy and narrowing or the pylorus (opening between the stomach and the duodenum. This prevents food travelling down into the small intestine. Leads to powerful peristalsis and then projectile vomiting.

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17
Q

How does pyloric stenosis present?

A

In the first few weeks of life. Thin, pale baby that is failing to thrive.
- projective vomiting
- firm mass in the upper abdomen (large olive) - the hypertrophic muscle
- hypochloric metabolic acidosis on blood gas ( as vomiting HCl acid from stomach)

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18
Q

What does a blood gas show in pyloric stenosis?

A

Hypochloric metabolic alkalosis ( as hydrochloric acid is lost in the vomit)

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19
Q

How is pyloric stenosis managed?

A
  • laparoscopic pyloromyotomy ( Ramstedt’s operation). Make incision in the smooth muscle to widen the canal and spinchter
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20
Q

How is pyloric stenosis diagnosed?

A

Abdominal ultrasound

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21
Q

What is biliary atresia?

A

A congenital condition where a section of the bile duct is either narrowed or absent. Causes cholestasis - hence prevents excretion of conjugated bilirubin.

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22
Q

How does biliary atresia present?

A

Shortly after birth with significant and persistent jaundice. ( >14 days in term and >21 days in premature)

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23
Q

What initial investigation is done for biliary atresia?

A

blood tests looking at the levels of conjugated and unconjugated bilirubin. (conjugated will be high - suggesting liver is working but it is not being excreted correctly)

24
Q

How is biliary atresia managed?

A

Surgery - ‘kasai portoenterostomy’.
Involves attaching a section of the small intestine to the opening of the liver.
This can prolong survival but often patients require a full liver transplant to resolve the condition.

25
Q

What is intussusception?

A

Where the bowel ‘invaginates’/telescopes into itself. This thickens the overall size of the outer bit of bowel and narrows the lumen of the folded inner bit.

26
Q

Who is intussusception most prevalent in?

A

Infants between 6 months to 2 years.
More common in boys.

Certain other medical conditions

27
Q

Which conditions are associated with intussusception?

A
  • concurrent viral illness (URTI)
  • Henoch-schonlein purpura
  • cystic fibrosis
  • intestinal polyps
  • Meckel diverticulum
28
Q

How does intussusception present?

A
  • severe colicky abdominal pain
  • pale, lethargic and unwell child
  • redcurrent jelly stool
  • RUQ mass on palpation - described as sausage
  • vomiting
  • intestinal obstruction (abdominal distention)
29
Q

How is intussusception diagnosed?

A

Ultrasound scan or contrast enema

30
Q

How is intussusception managed?

A
  • therapeutic enemas (pump contrast, water or air into the colon
  • surgical reduction
  • if gangrenous or perforated then surgical resection will be needed
31
Q

What are some complications of intussusception?

A
  • obstruction
  • gangrenous bowel
  • perforation
  • death
32
Q

What is hirschsprung’s disease?

A

A congenital condition where nerve cells of the myenteric plexus are absent in the distal bowel and rectum. Without this, there is no stimulation of peristalsis hence a loss of motility and then obstruction.

33
Q

What is the main pathophysiology of hirschsprung’s disease?

A

Absence of parasympathetic ganglion cells in the myenteric plexus of the GI tract.

34
Q

What other medical conditions are associated with hirschsprung’s disease?

A
  • down’s syndrome
  • neurofibromatosis
  • MEN type 2 (multiple endocrine neoplasia)
35
Q

How does hirschsprung’s disease present?

A

Severity depends on extent of bowel affected and age of presentation.
Can be acute intestinal obstruction straight after birth or more gradual with
- delay in passing meconium (>24hrs)
- chronic constipation since birth
- abdominal pain and distention
- vomiting
- poor weight gain and failure to thrive

36
Q

What is hirschsprung-associated enterocolitis and how does it present and managed?

A
  • Inflammation and obstruction of the intestine of a neonate with hirschsprung’s disease.
  • Normally 2-4wks after birth with fever, abdominal distention and bloody diarrhoea.
  • Can lead to toxic megacolon or bowel perforation.
  • Management - Urgent abx, fluid resus and decompression of the obstructed bowel.
37
Q

How is hirschsprung’s disease diagnosed?

A
  • abdominal xray
  • rectal biopsy to confirm - absence of ganglionic cells
38
Q

How is hirschsprung’s disease managed?

A

If acutely unwell
- fluid resus, management of obstruction. May need abx.
Definitive management
- surgical removal of affected section of bowel

39
Q

What is intestinal obstruction?

A

Where a physical obstruction prevents the flow of faeces through the bowel, leading to back pressure, vomiting and absolute constipation.

40
Q

What are some causes of intestinal obstruction in children?

A
  • meconium ileus
  • hirschsprung’s disease
  • oesophageal atresia
  • duodenal atresia
  • intussusception
  • imperforate anus
  • malrotation of the intestines with a volvulus
  • strangulated hernia
41
Q

How does intestinal obstruction present?

A
  • persistent vomiting - may be bilious
  • abdominal pain and distention
  • failure to pass stools or wind
  • abnormal bowel sounds - early on can be high pitched tinkling. Later will be absent
42
Q

How is intestinal obstruction diagnosed and what does this show?

A
  • abdominal xray - showing dilated loops of bowel proixmally and collapsed loops distally. There will also be a lack of air in the rectum
43
Q

What is GORD?

A

Where contents of the stomach reflux through the lower oesophageal sphincter into the oesophagus, throat and mouth.

44
Q

Why is reflux common in babies?

A

As there is immaturity of the lower oesophageal sphincter. Normally stops by 1 year.

45
Q

How does gastro-oesophageal reflux disease present?

A
  • normal for babies after larger feeds.
    However problematic reflux may have
  • chronic cough
  • hoarse cry
  • distress, crying or unsettled after feed
  • reluctance to feed
  • pneumonia
  • poor weight gain

Older children may have
- heartburn , epigastric pain, bloating and nocturnal cough

46
Q

What are some causes of vomiting in children?

A
  • GORD
  • Overfeeding
  • pyloric stenosis (projectile)
  • gastritis or gastroenteritis
  • appendicitis
  • infections - e.g. UTI, tonsilitis, meningitis
  • intestinal obstruction
  • bulimia
47
Q

How is reflux managed in babies?

A
  • small, frequent feeds
  • encourage burping to help milk settle
  • don’t overfeed
  • keep baby upright after feeding
  • if severe - Gaviscon can be mixed with feeds
  • thickened milk or specialised formulas
  • ranitidine
48
Q

What is IBD?

A

Inflammation of the GI tract with remission and exacerbation.
Two main types - Crohn’s disease and Ulcerative colitis

49
Q

What are the distinguishing features of crohn’s disease?

A

NESTS
- No blood or mucus
- Entire GI tract (from mouth to anus) - but terminal ileum is most affected
- Skip lesions
- transmural (full thickness) inflammation
- smoking is a risk factors

50
Q

What are the distinguishing factors of ulcerative collitis?

A
  • continuous inflammation
  • starts at rectum and moves UPwards
  • inflammation affects the superficial mucosa
  • bloody and mucus in stool
  • smoking is protected
  • associated with primary sclerosing cholangitis
51
Q

How does IBD present?

A

Flares of
- diarrhoea
- abdominal pain
- bleeding
- weight loss
- anaemia
- systemically unwell - fever, dehydration, tiredness
- extra-intestinal manifestations - e.g. clubbing

52
Q

What are extra-intestinal manifestations of IBD?

A
  • finger clubbing
  • erythema nodosum
  • episcleritis and iritis
  • inflammatory arthritis
  • primary sclerosing cholangitis (with UC)
53
Q

How is IBD diagnosed?

A
  • bloods - FBC, TFT, U+Es, LFTs, inflammatory markers
  • faecal calprotectin - released by the colon when inflamed
  • endoscopy - OGD and colonoscopy - gold standard
  • other imaging can be useful
54
Q

How is crohn’s disease managed?

A

Inducing remission
- steroids (oral pred or IV hydro)
- consider adding immunosupressants - e.g. azathioprine, methotrexate, infliximab

Maintaining remission
- first line medications are azathioprine or mercaptopurine
- lifestyle management - e.g. certain foods, well hydrated etc.

Surgery can be considered - but difficult if multiple parts of the GI tract are affected

55
Q

How is ulcerative colitis managed?

A

Inducing remission
- mild/ mod - give mesalazine
- severe - steroids (IV) +/- ciclosporin

Maintaining remission options
- mesalazine
- azathioprine
- methotrexate
- lifestyle management - e.g. certain foods, well hydrated etc.

Surgery - removal of the colon and rectum will remove disease (panproctocolectomy). Leaves a J pouch or permenant ileostomy.

Paediatrics (14 decks)

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