GI Flashcards
1
Q
Acute and Chronic causes of diarrhoea?
A
Acute:
* Gastroenteritis
* Nectrotizing entercolitis
* Intusseseption
* Volulus
Chronic
* Toddlers Diarrhoea
* Coeliacs
* IBD
* Allergies- non IgE mediated
2
Q
A toddler presents with diarrhoea. What are your differentials?
A
- Gastroenteritis
- Any infection e.g. viral URTIs, Chest infections, otitis media, UTI
- Antibiotic use
Chronic:
Lactose intolerance
Toddlers diarrhoea
3
Q
A 4 year old presents with diarrhoea. What are your differentials?
A
- Toddlers diarrhoea
- Parasites
- Overflow dirrhoea in constipation
- Lactose intolerance
- Coeliac disease
- Cystic fibrosis
4
Q
13 year old presents with diarrhoea. What are your differentials?
A
- Coeliacs disease
- Lactose intolerance
- IBD
- IBS
- Psychosocial- anxiety
5
Q
Main complication of diarrhoea in young children and babies?
A
- Dehydration
6
Q
Causes of dehydration?
A
- Inability to drink e.g. tonsillitis
- Excessive sweating: high fever, hot climate, cystic fibrosis
- Vomiting: Pyloric stenosis, viral infections, gastroenteritis
- Acute diarrhoea: viral/ bacterial gastroenteritis, food poisoning, antibiotics, any acute infection
- Burns
- Post surgery
- Polyuria- diabetes mellitus, diabetes insipidus
7
Q
Signs of severe dehydration in a baby/ child ?
A
- Sunken fontanelle- baby
- Sunken eyes
- Dry lips and mouth
- Thirst +++
- Tachycardia
- Delayed cap refill time
- Reduced skin turgor
- Reduced urine output
- Weight loss
8
Q
What is Coeliacs disease?
A
- Autoimmune condition caused by sensitivity to protein in gluten
- Repeated exposure leads to villous atrophy–> malabsorption
9
Q
What conditions are associated with Coeliacs?
A
- dermatitis herpetiformis
- Autoimmune disorders e.g. T1DM and autoimmune hepatitis
10
Q
What genes are associated with Coeliacs?
A
- HLA-DQ2
- HLA-DQ8
11
Q
Complications of Coeliacs disease?
A
- anaemia: iron, folate and vitamin B12 deficiency (folate deficiency is more common than vitamin B12 deficiency in coeliac disease)
- hyposplenism
- osteoporosis, osteomalacia
- lactose intolerance
- enteropathy-associated T-cell lymphoma of small intestine
- subfertility, unfavourable pregnancy outcomes
- rare: oesophageal cancer, other malignancies
12
Q
When should you think about investigating for Coeliacs disease?
NICE 2009- suggested
A
Signs and symptoms:
* Chronic or intermittent diarrhoea
* Failure to thrive or faltering growth in children
* Persisten or unexplained GI symptoms incl N&V
* Prolonged fatigue
* Reccurent abdo pain, cramping or distension
* Sudden or unexpected weight loss
* Unexplained iron- deficiency anaemia, or other unspecified anaemia
Conditions
* Autoimmune thyroid disease
* Dermatitis herpetiformis
* IBS
* Type 1 diabetes
* First degree relatives with coeliacs
13
Q
What investigations would you do for coealiacs?
A
Serology:
* tissue transglutaminase (TTG) antibodies (IgA) are first-choice according to NICE
* endomyseal antibody (IgA)
needed to look for selective IgA deficiency, which would give a false negative coeliac result
* anti-casein antibodies are also found in some patients
Endoscopic intestinal biopsy- duodenum, usually in children you use jejunal biopsy showing subtotal villous atrophy
May see the following:
* Crypt hyperplasia
* Increase in intraepithelial lymphocytes
* Lamina propria infiltration with lymphocytes
* anti-gliadin antibody (IgA or IgG) tests are not recommended by NICE
14
Q
Management of Coeliacs?
A
- Gluten- free diet
- Patients with coeliac disease often have a degree of functional hyposplenism-all patients with coeliac disease are offered the pneumococcal vaccine
- Coeliac UK recommends that everyone with coeliac disease is vaccinated against pneumococcal infection and has a booster every 5 years
- Currrent guidelines suggest giving the influenza vaccine on an individual basis.
15
Q
What contains gluten?
A
- wheat: bread, pasta, pastry
- barley: beer
- whisky is made using malted barley. Proteins such as gluten are however removed during the distillation process making it safe to drink for patients with coeliac disease
- rye
- oats- although GF, some react to them, also usually made in factory that is not GF so cannot have
rice
potatoes
corn (maize)
are GLUTEN FREE
16
Q
Acute and Chronic causes of constipation?
A
Acute:
* Dehydration
* Bowel obstruction
Chronic
* Functional constipation
* Hirschsprung’s disease
* Secondary to other conditions e.g. hypothryroidism, coeliac disease, CF
Idiopathic is the most common cause
17
Q
Signs of constipation in children < 1 year old ?
A
Stool pattern:
* Fewer than 3 complete stools per week (type 3 or 4 on Bristol Stool Form Scale) (this does not apply to exclusively breastfed babies after 6 weeks
of age)
* Hard large stool
* ‘Rabbit droppings’ (type 1)
Symptoms associated with defecation
* Distress on passing stool
* Bleeding associated with hard stool
* Straining
History
* Previous episode(s) of constipation
* Previous or current anal fissure
18
Q
Presentation of constipation of child > 1 year?
A
Stool Pattern:
* Fewer than 3 complete stools per week (type 3 or 4)
* Overflow soiling (commonly very loose, very smelly, stool passed without sensation)
* ‘Rabbit droppings’ (type 1)
* Large, infrequent stools that can block the toilet
Symptoms associated with defecation:
* Poor appetite that improves with passage of large stool
* Waxing and waning of abdominal pain with passage of stool
* Evidence of retentive posturing: typical straight-legged, tiptoed, back arching posture
* Straining
* Anal pain
History
* Previous episodes of constipation
* Previous or current anal fissure
* Painful bowel movements and bleeding associated with hard stools
19
Q
What points to idiopathic constipation as opposed to more serious condition?
Think Timing, Growth and Diet
A
Timing:
* starts after a few weeks of life
* Obvious precipitating factor e.g. fissure, change of diet, timing of potty/toilet training or acute events such as infections, moving house, starting nursery/school, fears and phobias, major change in family, taking medicines
Passage of meconium < 48 hours
Growth:
* Generally well, weight and height within normal limits, fit and active
Neuro/locomotor
* No neuro problems in legs and normal locomotor development
Diet:
* Changes in infant formula
* Weaning
* insufficient fluid intake or poor diet
20
Q
Red flags in children with constipation?
A
Timing:
* Reported from birth or first few weeks of life
Failure to pass meconium w/in <48 hours
Stool pattern:
* Ribbon stools
Growth:
* faltering growth is amber flag
Abdomen:
* Distension (+/- vomiting)
Other:
* Disclosure or evidence that raises concerns over possibility of child maltreatment
21
Q
What is a necessity to assess for in a child with constipation?
A
FAECAL IMPACTION
Suggestive features incl:
* symptoms of severe constipation
* overflow soiling
* faecal mass palpable in abdomen
22
Q
Managment of constipation if there is faecal impaction?
A
- polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen as the first-line treatment
- add a stimulant laxative if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks
- substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if Movicol Paediatric Plain is not tolerated
- inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain
23
Q
Conservative management of constipation in children?
A
- Reward charts e.g. star charts
- Increased dietary fibre
- Adequate hydration/fluids
24
Q
Treatment of constipation (w/o faecal impaction)
A
- first-line: Movicol Paediatric Plain
- add a stimulant laxative if no response
- substitute a stimulant laxative if Movicol Paediatric Plain is not tolerated. Add another laxative such as lactulose or docusate if stools are hard
- continue medication at maintenance dose for several weeks after regular bowel habit is established, then reduce the dose gradually
- DR LUYT: duration for the same as symptoms have been there e.g. 3 weeks of symptoms- 3 weeks of treatment
25
How to treat children < 6 mnths for constipation?
* bottle-fed infants: give extra water in between feeds. Try gentle abdominal massage and bicycling the infant's legs
* breast-fed infants: constipation is unusual and organic causes should be considered
26
Management of constipation of infants who are or have been weaned?
* offer extra water, diluted fruit juice and fruits
* if not effective consider adding lactulose
27
What shoudl you ask in Hx when child comes in with constipation?
* Infrequent but normal stools are not indicators of constipation
* Ask about: hardness of stool, painful defecation, crampy abdo pain and blood on the stool or toilet
* Hx of anal fissure is significant
* Preciptating events
* Ask about diet
* Soiling
* Abdo pain
* Developmental milestones
* Ask about pregnancy, birth and meconium passage
28
Examination in constipation?
* Growth: review growth chart as Hirschprungs disease accompanied by failure to thrive
* Abdo exam- may be able to feel stool in LLQ
* Anorectal examination: anal fissures may be present. Do not perform DRE
29
What is the commonest cause of vomitting in infancy?
* GORD
* Around 40% infants regurgitate their feeds to a certain extend so degree of overlap w normal physiological processes
30
RF for GORD?
* Preterm delivery
* Neuro delivery
31
Features of GORD in infants?
* typically develops before 8 weeks
* Vomiting/regurgitation
* Milky vomits after feeds
* May occur after being laid flat
* Excessive crying, esp while feeding
32
Management of GORD in infants?
| 2015 NICE
* advise regarding position during feeds - 30 degree head-up
* infants should sleep on their backs
* ensure infant is not being overfed (as per their weight) and consider a trial of smaller and more frequent feeds
* a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum)
* a trial of alginate therapy e.g. Gaviscon. Alginates should not be used at the same time as thickening agents
* NICE do not recommend a proton pump inhibitor (PPI) to treat overt regurgitation in infants and children occurring as an isolated symptom. A trial of one of these agents should be considered if 1 or more of the following apply:
* unexplained feeding difficulties (for example, refusing feeds, gagging or choking)
* distressed behaviour
* faltering growth
If severe complications and medical treatment does not work: consider fundoplication
| prokinetic agents e.g. metoclopramide should only be used with specialis
33
Complications of GORD in infants?
* Distress
* Failure to thrive
* Aspirtion
* frequent otitis media
* In older children: erosion may occur
34
A 6 week year old infant presents with worsening vomitting for the last 2 weeks. What are your differentials?
* Pyloric stenosis
* Milk allergy
* Overfeeding
* GORD
* Gastroenteritis
* Gastric volvulus
35
What is Gastroenteritis?
| DL tutorial
* Sudden onset of diarrhoea, with or without vomitting
* Most cases due to an enteric virus; can be caused by bacteria or protozoa
* V common- 10% of children present annually
* Usually self- limiting not needing medical attention but can be life threatening
36
What to ask in hx for suspected GE?
* Diet
* Blood in stools and recent bowel habits
* Presence of fever
* Anyone around him unwell
* Immunisations
* Travel hx
* Rest of hx: PMH, Dhx, Shx, Fhx, ICE
| DL tutorial
37
What to ask in hx for suspected GE?
* Diet
* Blood in stools and recent bowel habits
* Presence of fever
* Anyone around him unwell
* Immunisations
* RF for dehydration
* Urine output, fluid intake and are they floppy?
* Travel hx
* Rest of hx: PMH, Dhx, Shx, Fhx, ICE
| DL tutorial
38
What are the RF for dehydration in GE?
* 5 or more stool in 24 hours
* 3 or more vomits in 24 hours
* Age < 12 months ( < 6 months is worse)
* Intake (worse if not breast feeding)
39
Examination to assess for hydration?
* Cap refill
* Skin tugor
* Mucus membranes
* Fontanelles
* Urine output
40
How do you diagnose Gastroenteritis?
Clinical: suspect if sudden change in stool consitency to loose/ watery and/or sudden onset of vomiting
Stool microbiology if:
* septicaemia is suspected
* Blood and/or mucus in stools
* Child is immunocompromised
* Recent travel abroad
* Diarrhoea has not improved after 7 days
* Diagnosis of GE uncertain
And then treat accordingly
* Assess dehydration and shock
| DL tut
41
What clinical features would lead to you consider other diagnoses other than GE in a pt with diarrhoea and/or vomitting?
* Fever > 38 if less than 3 mnths; > 39 if older
* Dyspnoea/tachypnoea
* Altered LOC, bulging fontanelle, non-blanching rash
* Bilious vomiting; blood/ mucus in stool
* Severe/localised pain, rebound tenderness, abdo distension
42
How to assess for dehydration and shock?
| What to ask about, look out for, red flags and hypernatraemia
Consider RF
Ask about:
* Appear unwell
* altered responsiveness (irritable or lethargic)
* Decreased urine output
* Pale, mottled skin, cold extremities
Look for:
* Altered responsiveness
* Skin colour changes, extremity temperature
* Mucous membranes
* Sunken eyes
* Tissue turgor
* Tachypnoea, tachycardia, cap refill, BP
Red flags:
* Altered level of consciousness
* Tachycardia
* Tachypnoea
* Sunked eyes, reduced tissue turgor
Consider hypernatraemia if:
* Jittery
* Increased muscle tone
* Hyperreflexic
* Convulsions
* Drowsiness
* Coma
43
Management of GE?
Fluid management
GE without dehydration:
* continue breast feeding and other milk feeds
* Encourage fluid intake
* Discourage fruit juices/ fizzy drinks
* Offer ORS as a supplement if at risk of dehydration
GE WITH dehyrdation incl hypernatraemia:
* Use low osmolality ORS for oral rehydration
* GIve 50ml/kg for fluid deficit over 4 hours as well as maintenance fluid
* GIve ORS frequently and in small amounts
* Consider supplementation with usual feeds if ORS refused (if no red flags)
* Monitor response to ORS with regular clinical assessment
Use IV fluids if:
* Shock suspected or confirmed
* Child with red flag symptoms/ signs despite ORS
* Persistent vomiting of ORS
44
What are the points to remember if using IV for rehydration in GE?
* Use isotonic solution (0.9% NaCl +/- 5% glucose) for rehydration and maintenance
* For those with suspected/ confirmed shock- give 100ml/kg bolus
* For those without shock- add 50ml/kg for fluid deficit (or the deficit is weight in kg x % dehydration)
* Measure U&Es and glucose regularly
* Consider IV potassium supplementation when plasma potassium is known
* If hypernatraemic dehyration- give over 48 hours to avoid cerebral odema
45
The child with GEhas now been rehydrated. How would you manage their nutrition?
* Give full strength milk straight away
* Reintroduce child's usual solid foods
* Avoid fruit juices/carbonated drinks until diarrhoea has settled
46
What advice would you give to a parent of a child who has GE?
(hygiene, school return)
* Wash hands with soap (liquid) and warm water
* Wash hands after going to the toilet (for children) or changing nappies (parents/carers) or before handling any food
* Towels used by infected children should not be shared
* Child not to attend school or childcare whilst they have D or V
* Child not to go back to school until at least 48 hours after last D/V
* Child not to swim for 2 weeks after last episode of diarrhoea
47
What is Ulcerative colitis?
* Diffuse mucosal inflammation or the rectum, extending proximally
* Subdivision into distal (proctitis and proctosigmoiditis) and extensive disease (left-sides or extensive colitis and pancolitis)
48
What is Crohn's disease?
* Patchy transmural inflammation affecting one or several segements of the intestinal tract
* Defined by anatomically location or pattern of disease
49
History that would make you suspect IBD? Differentiate between UC and Crohns.
* Adolescent or young adult
* Abdominal pain
* frequent Diarrhoea e.g. 5 or more a day
* Weight loss
* Lethargy
* Ulcers
* Joint pain
* Fhx of IBD
* Erythema nodosum
* Waking up at night to use the toilet
Crohn's:
* Weight loss
* Smoking makes it worse
* Perianal disease
* Less likely to have blood in stools
* Low grade fever
* Mildly anaemia
UC:
* Blood in stools
* Mucus in stools
* No perianal disease
50
Histology in Crohns?
* Fissuring ulcers
* Non-caseating granuloma
* Lymphoid and neutrophil aggregates
51
Endoscopy findings Crohns?
* Apthous ulcer
* Cobblestone appearance
52
Xray in Crohn's?
* Tapering at hepatic flexure
53
Investigations in IBD?
* Bloods: Hb (anaemia), Increased ESR/ CRP, hemanitics (folate and B12), LFTs (for primary sclerosisng cholangitis), albumin
* Microbiology: Stool culture- rule out infective causes and faecal calprotection (raised in IBD)
* Imaging: Xray, Endoscopy, Barium enema (Crohns) or Double contrast enema (UC)
54
Endoscopy findings for UC?
* Decreased goblet cells
* Crypt abcesses
55
Endoscopy findings for UC?
* Decreased goblet cells
* Crypt abcesses
56
Xray findings in UC?
* mucosal odema
* Thumbprinting
57
Double contrast enema findings in UC?
* Lead pipe colon
58
Mangagment of Crohns disease?
* Liquid diet- induces remission (not sure why)
* Can use steroids to induce remission too
* Maintenance with azthioprine or mercaptourine
59
Mangement of UC?
Aminosalicylates for induction of remission for mild/moderate disease
IV steroids for induction of severe disease
Aminosalicylates for maintenance
60
Associations of IBD?
Crohns:
* Arthritis
* Episcelritis
* Asymmetric erythema nodosum
UC:
* Arthiritis
* Primary sclerosing cholangitis
* Uveitis
61
What is the aetiology of Acute liver failure in children?
Damage to hepatocytes by:
* Infection: acute viral hep (A,B); EBV may precipitate mononucleosis hepatitis
* Drugs/ inadvertent poinsoning: paracetamol, isoniazid, halothane, poisonous mushrooms
* Reye syndrome: <14 years old is associated with an acute non-inflammatory encephalopathy with associated liver damage (esp w concomitant vericella infection)
62
How can acute liver failure present?
* May present within hours
* Jaundice
* Encephalopathy
* Coagulopathy
* Hypoglycaemia
* Other elctrolyte disturbances
63
How may encephalopathy present?
* Young children: alternating periods of irritability and confusion with drowsiness
* Older children: aggression and being unusually difficult
64
Investigations in acute liver failure?
Bloods: LFTs: Increased bilirubin (although may be normal in the early stages),increased ALT, AST,ALP, Coag- deranged clotting, increased plasma ammonia and decreased glucose
ABG: frquently associated with acid/base imbalance
Viral serology: detect hepatitis
Imaging: CT/MRI brain: may show cerebral oedema in encephalopathy
EEG: may show acute hepatic encephalopathy
65
Managment of acute liver failure?
Treatment of complications:
Hypoglycaemia: Dextrose infusion
Sepsis: broad spec abx
Coagulation defect: FFP and PPI to prevent gastric bleeding. Vit K not usually indicated- if needed then usually indication for liver transplantation
Cerebral oedema: fluid restriction and diuresis with mannitol
Liver transplant: prothrombin time is the best marker of liver failure
66
Complications of acute liver failure?
* Cerebral oedema
* Haemorrhage from gastritis or coagulopathy
* Sepsis
* Pancreatitis
67
Poor prognostic signs for acute liver failure?
1. Liver starting to shrink in size
2. Rising bilirubin with falling transaminases
3. Increase coagulation defect
4. Progression to encephalopathy and coma
68
What hepatitis viruses have vertical transmission?
* B
* C
69
How is Hep A spread?
* Faeco-oral route
70
Epidemiology of Hep B?
* Most common cause of hepatitis globally
* High prevalence regions include sub-Saharan Africa, Asia and the Pacific Islands.
* Decline of disease in children and adolescents in the UK is due to routine vaccination
* Incubation period usually 60-90 days.
71
Features of Hep B Infection?
* Only 5% of children have jaundice and severe symptoms, but the majority cannot clear the infection and develop chronic disease.
* 30-50% of adults experience jaundice, fever, malaise, and darkening of urine and lightening of stool. Some develop fulminant liver failure with decompensation (ascites, encephalopathy etc.). Risk of developing chronic disease is low (<5%).
72
Serology of Hep B?
* HBsAg is detected 3-5 weeks after infection. If present for >6 months: Chronic disease (5-10% of infections).
* Anti-HBs implies immunity- negative in chronic disease
* Anti-HBc: previous or current infection. In current infection IgM raised for about 6 months, after will be IgG
* HbeAg- marker of infectivity
73
Management of chronic Hep B?
* Pegylated interferon-alpha
* Antivirals: tenofovir, entercavir and telbivudine
74
Features of Hep C?
Only 30% of people will develop features e.g.:
* transient rise in serum aminotransfereases/ jaundice
* fatigue
* arthralgia
75
Investigations for Hep C?
* HCV RNA is the investigation of choice to diagnose acute infection
* whilst patients will eventually develop anti-HCV antibodies it should be remembered that patients who spontaneously clear the virus will continue to have anti-HCV antibodies
76
What % of patients will go on to have chronic hep C?
* 55-85%
77
What is chronic Hep C?
* Persistence of HCV RNA in the blood for 6 months
78
Complications of chronic hep C?
* rheumatological problems: arthralgia, arthritis
* eye problems: Sjogren's syndrome
* cirrhosis (5-20% of those with chronic disease)
* hepatocellular cancer
* cryoglobulinaemia: typically type II (mixed monoclonal and polyclonal)
* porphyria cutanea tarda (PCT): it is increasingly recognised that PCT may develop in patients with hepatitis C, especially if there are other factors such as alcohol abuse
* membranoproliferative glomerulonephritis
79
Management of chronic Hep C?
* treatment depends on the viral genotype - this should be tested prior to treatment
* the management of hepatitis C has advanced rapidly in recent years resulting in clearance rates of around 95%.
* the aim of treatment is sustained virological response (SVR), defined as undetectable serum HCV RNA six months after the end of therapy
* currently a combination of protease inhibitors (e.g. daclatasvir + sofosbuvir or sofosbuvir + simeprevir) with or without ribavirin are used
80
Complications of Chronic Hep C treatment?
ribavirin - side-effects: haemolytic anaemia, cough. Women should not become pregnant within 6 months of stopping ribavirin as it is teratogenic
interferon alpha- no longer recommned - side-effects: flu-like symptoms, depression, fatigue, leukopenia, thrombocytopenia
81
What is Hep A?
Hepatitis A is typically a benign, self-limiting disease, with a serious outcome being very rare.
82
Features of Hep A?
* flu-like prodrome
* abdominal pain: typically right upper quadrant
* tender hepatomegaly
* jaundice
* deranged liver function tests
83
Vaccination programme for Hep A?
an effective vaccine is available
after the initial dose a booster dose should be given 6-12 months later
84
Who should get vaccinated for Hep A?
* people travelling to or going to reside in areas of high or intermediate prevalence, if aged > 1 year old
* people with chronic liver disease
* patients with haemophilia
* men who have sex with men
* injecting drug users
* individuals at occupational risk: laboratory worker; staff of large residential institutions; sewage workers; people who work with primates
85
Causes of acute abdo pain in children + supporting features?
* Acute appendicitis: anorexia, central pain localising to RIF, peritonism, tachycardia
* Henoch-schonlein purapura: purpuric rash on legs, joint pain
* UTI: dysuria, frequency, back pain, bedwetting, vomiting
* Constipation: hard or infrequent stool, mass in LIF
* Intestinal obstruction: bile stained vomting, abdo distension
* Intussusception: intermittent screaming/colic, shock, redcurrent jelly stool, 3-24 months
* DKA
* Lower lobe pneumonia: signs of pneumonia
* Peptic ulcer: pain at night, relief with milk
* Renal calculi: symptoms of hydronephrosis
* Gastroenteritis: D&V
* Hepatitis
* Mesenteric adenitis
86
Ddx for recurrent abdo pain?
* IBS/IBD
* Idiopathic constipation
* Coeliacs
* Psychogenic
* Sickle cell
* Gynae problems e.g. ovarian cyst or dysmenorrhoea
87
Examination for abdo pain?
* General observations
* Abdo exam- signs of peritonism, rebound tenderness, guarding
* Mesenteric adenitis: often palpable lymphadenopathy elsewhere
88
Investigations in abdo pain?
Bedside:
* urine dip for UTI
* BM: DKA
Bloods/Lab:
* FBC: WCC count
* CRP: high in infection/ IBD
* U&Es: any metabolite abnomalities/ AKI for dehydration
* LFTs: to rule out hepatitis
* Urine MC&S
Imaging:
* Axr: dilated bowel loops in obstruction, faecal loading in constipation, abnormal gas pattern in intussuception
* USS of abdo: exclude renal tract abnormality
* Pelivc USS: any gynae causes
* Barium enema: for inussusception or UC (double contrast), Crohns
* Barium swallow and follow-through: oesophagitis and reflux, peptic ulcers
* Endoscopy: oesophagitis and reflux, peptic ulcer and IBD
89
Causes of vomiting in newborns and infants? Mention some distinguishing factors.
* Overfeeding
* GORD: may cause apnoea and failure to thrive, positional vomiting
* Pyloric stenosis: 4-6 weeks old, projectile vomiting after feed, hungry after vomiting, palpable 'olive' in abdo
* Whooping cough: paroxysmal cough
* Small bowel obstruction e.g. congenital atresia or malrotation: bile stained vomit, presents soon after birth, may have distension
* Constipation
* Systemic: Menigitis, UTI/ pyelonephritis
90
Causes of vomiting in older children?
* Gastroenteritis: usually have diarrhoea, dehydration
* Migraine
* Raisied ICP: effortless vomiting, neuro signs, papilloedema
* Bulimia
* Toxic ingestion or medications
* Pregnancy
91
Examination in child who is vomiting?
* Check for dehydration esp if presenting with GE
* Abdo exam: feel for mass in neonates 'olive': pyloric stenosis, check for abdominal distension: intestinal obstruction
* Neuro exam incl checking for papilloedema and HTN in cases of suspected raised ICP
* Brudzinski and kernigs sign if suspecting meningitis
92
Investigations in vomiting?
Bedside: Urine dip- rule out UTI, ECG- may have electrolyte disturbances that can cause arrythmias, BM- check for DKA, CBG- metabolic disturbances
Bloods: FBC- raised WCC for infection, U&Es- assess electrolyte disturbances and dehydration, CRP- for inflammation
Imaging: pH monitoring and barium swallow-may show significant GORD, upper GI contrast study- if bilious vomiting in newborn- to exclude malrotation, USS of pylorus- if pyloric stenosis is suspected
93
Lightning learning Hirschprung's disease
94
lightning learning viral gastroenteritis
95
lightning learning billous vomiting
