GI Flashcards
What is intussusception
Invagination of the proximal bowel into a distal segment
i.e. bowel telescopes into itself
Where in the bowel does intussusception commonly occur
Commonly involves ileum passing into the caecum through the ileocecal valve
What age does intussusception typically affect children
Infants aged 6 -18 months
Give 4 conditions associated with intussuception
- Concurrent viral illness
- Meckel diverticulum
- CF
- Henoch-Schonlein purpura
What is the investigation of choice for stable children with suspected Meckel’s diverticulum
A technetium scan
Give 5 ways intussuception may present
- Paroxysmal, severe colicky abdo pain
- Blood and mucus in stool - redcurrant jelly stool (late sign)
- Sausage-shaped palpable mass
- inconsolable crying - may draw up legs
- Vomiting - may be billous depending on the location
Investigations for intussuception
- Abdo USS (diagnostic) - target/doughnut sign
- Abdo XR - distended small bowel, absence of gas in large bowel
How is intussuception managed
- IV fluid
- Reduction by rectal air insufflation (enema)
- Surgical reduction
When is surgical reduction required for intussuception
- If an air enema is unsuccessful
- Signs of peritonitis
Give 4 complications of intussuception
- Hypovolaemic shock
- Venous obstruction due to stretching and constriction of the mesentery
- Bowel perforation
- Gangrenous bowel
What is pyloric stenosis
progressive hypertrophy of the pyloric sphincter causing gastric outlet obstruction
At what age does pyloric stenosis typically present
2 - 8 weeks of age
3 RFs of pyloric stenosis
- boys
- maternal FHx
- First born
Clinical presentation of pyloric stenosis (4)
- Non-billous, projectile vomiting after every feed
- Olive sized pyloric mass
- Weight loss
- Dehydration
How is pyloric stenosis investigated? Give positive findings
- Abdo ultrasound - pyloric hypertrophy
- Chemistry panel: Blood gas - Hypochloremic, hypokalaemic metabolic alkalosis, low plasma Na
How is pyloric stenosis managed
- IV fluids - correct metabolic disturbance
- (Ramstedt’s) Pyloromyotomy
What is Hirschsprung’s disease
A congenital condition where parasympathetic ganglionic cells of the myenteric plexus are absent in the distal bowel and rectum
Explain the pathophysiology of hirschsprung’s disease
- parasympathetic neuroblasts fail to migrate from the neural crest to the distal colon
- the nerve plexus is responsible for stimulating peristalsis of the large bowel
- the aganglionic section of the colon does not relax, causing it to become constricted (uncoordinated peristalsis)
- this leads to loss of movement of faeces and bowel obstruction
What length of the colon is affected in Hirschsprung’s disease
always located distally, but length of the segment varies
* mc confined to the rectosigmoid
* Can affect entire colon
The entire colon can be affected by Hirschsprung’s disease. What is the name for this
total colonic aganglionosis
When is Hirschsprung’s disease typically diagnosed
Within first year of life
Give 3 conditions associated with Hirschsprung’s disease
- Down’s syndrome
- multiple endocrine neoplasia type IIA
- Neurofibromatosis
Presentations of Hirschsprung’s disease (5)
- Abdo distension
- Billous vomiting
- Chronic constipation usually without soiling
- Explosive passage of liquid and foul stool following rectal exam
- Failure to pass meconium in 24h
What investigations should be done for Hirschsprung’s disease
- Initial diagnosis: contrast enema
- Abdo XR - dilated colon
- Suction rectal biopsy (GS) - absence of ganglion cells + increased activity of acetylcholinesterase
How is typical Hirschsprung’s disease managed
- Bowel irrigation/ rectal washouts
- Surgery: removal of distal aganglionic segment
How is total colonic aganglionosis managed
- Colectomy
- Ileo-procto anastomosis
- Protective ileostomy with closure later in life
What is Hirschsprung-associated enterocolitis
Inflammation and obstruction of the intestine occasionally occurring in infants with Hirschsprung’s disease
Why is Hirschsprung enterocolitis life threatening
Can lead to toxic megacolon and perforation of the bowel
How is Hirschsprung enterocolitis treated
- Bowel irrigation
- Urgent Abx - Oral/ IV metronidazole
- IV fluids
- Decompression of obstructed bowel
What is the cause of most cases of constipation in children
Idiopathic / functional constipation
Give 4 secondary causes of constipation in children
- Hirschsprung disease
- hypothyroidism
- coeliac disease
- lower spinal cord problems
How does constipation present in children
- Less than 3 stools a week
- Large, infrequent stools that can block the toilet
- Straining and painful passages of hard stools
- Overflow soiling caused by faecal impaction
- poor appetite
- retentive posturing: typical straight-legged, tiptoed, back arching posture
Give 4 red flag symptoms associated with constipation in children
- failure to pass meconium within 24h of life (Hirschsprung’s or CF)
- failure to thrive (coeliac, hypothyroidism)
- abnormal lower back/ bum (spina bifida occulta)
- Perianal bruising or multiple fissures (sexual abuse
How is constipation managed in children
- correct any reversible conditions - high fibre diet, good hydration
- Laxatives: 1st movicol (macrogol) , add stimulant (senna) if no response
- Faecal impaction: disimpaction regimen followed by maintenance (movicol and stimulants)
- encourage and praise using the toilet
What is Meckel’s diveticulum
Congenital diverticulum (outpuching) of the small intestine containing ileal, gastric and pancreatic mucosa
How does Meckel’s diverticulum typically present
- Abdominal pain
- Large painless rectal bleed in children age 1-2 years
- Obstruction secondary to an omphalomesenteric band, intussusception and volvulus
What is biliary atresia
Obstruction of the biliary tree due to sclerosis of the bile duct, reducing bile flow
Describe the epidemiology of biliary atresia
- mc in Females
- Neonatal cholestasis presents within 2-8 weeks of life
- Associated with CMV
Describe the 3 types of biliary atresia
- Type 1: Common duct is obliterated, proximal ducts are patent
- Type 2: Atresia of the cystic duct in the porta hepatis
- Type 3: mc, atresia of the right and left ducts to the level of the porta hepatis
Describe the presentation of biliary atresia
typically presents in the first few weeks of life
* jaundice extending beyond physiological 2 weeks
* dark urine and pale stools
* appetite disturbance
* abnormal growth
* hepatosplenomegaly
How is biliary atresia investigated, give positive findings
- serum bilirubin: conjugated bilirubin high
- LFTs raised
- Alpha 1 antitrypsin to rule out deficiency
- Sweat test to rule out CF
- USS of the biliary tree and liver
How is biliary atresia managed
- surgical dissection of structural abnormalities
- antibiotics following surgery
Give 2 complications of biliary atresia
- cirrhosis with eventual hepatocellular carcinoma
- progressive liver disease
What is intestinal malrotation
twisting loop of bowel leading to intestinal obstruction
How does intestinal malrotation and volvulus typically present in children
- billous vomiting
- obstruction: absent bowel sounds, constipation, distended abdomen
- poor appetite
- abdo pain
- commonly affects neonates in the first 30 days of life
How is malrotation and volvulus investigated
Upper GI contrast study - DJ flexure more medially placed
Ultrasound - abnormal orientation of superior mesenteric artery and vein
Management of intestinal malrotation with volvulus
Ladd’s procedure (includes division of Ladd bands and widening of the base of the mesentery)
What is Gastro-oesophageal reflux
where contents from the stomach reflux through the lower oesophageal sphincter into the oesophagus, throat and mouth
Give 2 RFs of gastro-oesophageal reflux in children
- preterm delivery
- neurological disorder
When does gastro-oesophageal reflux typically develop in infants?
before 8 weeks of age
What are the common features of gastro-oesophageal reflux in children
- Vomiting or regurgitation
- Milky vomits after feeds
- Reflux may occur after being laid flat
- Excessive crying, especially while feeding
How is gastro-oesophageal reflux managed in children
- Small, frequent meals
- Burping regularly to help milk settle
- Not over-feeding
- Keep the baby upright after feeding (i.e. not lying flat)
- thickened milk/ formula or gaviscon mixed with feeds
What is infantile colic?
typically occurring in those less than 3 months old, characterized by excessive crying and pulling-up of the legs, often worse in the evening
What is gastroenteritis
inflammation from the stomach to the intestines and presents with nausea, vomiting and diarrhoea
What are the most common causes of gastroenteritis in children
rotavirus and norovirus
What is the main risk of gastroenteritis in children
severe dehydration
Give 4 differentials of diarrhoea in children
- most common cause in the developed world is cows’ milk intolerance
- coeliac disease
- post-gastroenteritis lactose intolerance
- Toddler’s diarrhoea
How is gastroenteritis managed
- Children need to stay off school until 48 hours after the symptoms have completely resolved
- rehydration
