GI Flashcards
1
Q
Paeds Common GI clinical presentations
A
- Pain
- Vomiting (freq., content, ?blood)
- Lack of appetite
- Bloating
2
Q
Infectious Gastroenteritis
A
an infection of the gastrointestinal tract by a virus / bacteria
3
Q
Paeds dehydration assessment
A
- ?Active
- ?chatty
- ?Playful
- ?Smiley
- Skin tugor
- RR
- HR
- O2 sat.
4
Q
Paeds diarrhoea without dehydration
A
- Obtain weight
- Electrolyte replacements
- push fluids
- Monitor urine output
5
Q
When to admit to hosp with diarrhoea
A
- Sx of dehydration persistent
- high risk to dehydration <6months
- 6-7 intervals daily
- Sx not improved in 72 hours
- Hx of premature birth, low weight
- Urine output (urine in the last 12 hours)
6
Q
Constipation Adbo examination
A
- Abdo examinations
- Height
- Weight
- Check anus region
7
Q
Abdo examination findings
A
- Firm stool on palpation
- Tenderness
- distention
8
Q
Paeds constipation aetiology
A
- Functional (95%)
- Organic causes (5%)
9
Q
Constipation organic causes
A
-
Hirschprungsdisease ,spinal cord deformities, anal stenosis
lead to constipation in first few weeks of life
Infants and children(weaned): -
Cowsmilk intolerance-
Children who are physical inactive/impaired mobility ( e.g.Downs, cerebral palsy ) - Perianal Strep A infection rare but treatable cause of constipation
- Lichenatrophicuscauses trauma to anus leading to constipation
- Direct anal trauma unusual and should lead to suspect sexual abuse
- Refusal to pass stools associated with autism and ADHD
10
Q
Meconium
A
1st stool should pass within the first 24 hours after birth
11
Q
Hirschprungsdisease
A
Abscence of ganglion cell in the megacolon
12
Q
Constipation Mx
A
osmoticLifestyle: High fibre, high fluid, activities
1st line: Macrogol (osmotic laxative)
if not improving in 2/52
- add in senna (stimulant) +/- lactulose (osmotic)
13
Q
Chronic constipation duration
A
8 wks or more
14
Q
Constipation peak incidence
A
2-3 years
15
Q
Constipation RED FLAGS
A
- NO meconium in the first 48 hours (cystic fibrosis or Hirschsprung’s disease)
- Ribbon stool (anal stenosis)
- Abdo distention +/- vomiting (Hirschsprung’s or intestinal obstruction)
- Encopresis (faecal incontinence)
- Rectal bleeding
DO NOT initiate constipation Tx in primary care
Urgent referral or admit
16
Q
Constipation Amber FLAGS
A
- Evidence of faltering growth, developmental delay, or concerns about wellbeing
Can treat constipation in primary care whilst waiting for assesment
Refer to paeds
17
Q
Constipation WITH faecal imapction
A
- Macrogol disimapction regimen
- if not improving post 2/52 add senna
- if macrogol not tolerated subs with stimulant laxative +/- lactulose
18
Q
Breastfed infants stool
A
- watery, loose, poo frequently (6-8 times daily)
19
Q
Paeds gastroenteritis common causative virus
A
Norovirus
Rotavirus (vaccinated against)
20
Q
Diarrhoea Hx taking
A
- up to date with vaccine??
21
Q
Diarrhoea advice for social setting
A
- Advise children should not attend any social settings until at least 48 hours after the last episode of diarrhoea or vomiting
- should not attend swimming pool for unless 2/52
22
Q
A
22
Q
Gastro-oesophogeal reflux – Risk Factors
A
- Premature birth.
- Parental history of heartburn or acid regurgitation.
- Hiatus hernia.
- History of congenital diaphragmatic hernia
- History of congenital oesophageal atresia
- Neurodisability.
23
Q
Gastro-oesophogeal reflux – Management
A
- Breastfeeding assessment.
- Review the feeding history.
- Reduce the feed volumes only if excessive for the infant’s weight.
- Offer a trial of smaller, more frequent feeds (while maintaining an appropriate total daily amount of milk) unless the feeds are already small and frequent.
- If cow’s milk allergy is suspected then it is recommended that there should be complete elimination of cow’s milk from the diet (or the mother’s diet if breastfeeding) for two to three weeks and observing if symptoms resolve.
Look at other’s diet as well
24
GORD safety netting
- Advise parents and carers that a review is required if:
- Regurgitation becomes persistently projectile.
- There is bile-stained vomiting or haematemesis.
- There are new concerns - eg, marked distress, feeding difficulties or faltering growth.
- There is persistent, frequent regurgitation beyond the first year of life
24
Pyloric stenosis Definition
In pyloric stenosis, hypertrophy of the pyloric sphincter results in narrowing of the pyloric canal. It is the most common cause of gastric outlet obstruction in the 2 to 12-week-old
25
Pyloric stenosis-Presentation
- Around 2-8 weeks of age
- Projectile non-bilious vomiting after each feed
with the baby remaining hungry
Vomiting increases in frequency over several days
Vomiting also increases in intensity until it becomes projectile.
Slight haematemesis may occur.
Persistent hunger, weight loss, dehydration, lethargy, and infrequent or absent bowel movements may be seen.
26
Pyloric stenosis examination findings
- olive shape mass at RUQ (hypertrophic pylorus)
27
Coeliac-Presentation
Presentation is varied EASILY MISSED and ranges from
Diarrhoea
abdominal pains
failure to thrive/faltering growth
iron-deficiency anaemia
Tiredness
28
Coeliac potent sign
Failure to thrive - weight and height
29
Risk factors for coeliac disease
Family hx of coeliac
Autoimmune disorders
type 1 DM
thyroid disease
Downs syndrome
30
Management of coeliac disease
strict lifelong gluten free diet
Under the paediatrician
Dietician
look for common deficiencies including iron, vitamin D, vitamin B12, and folate. All patients with coeliac disease should be recommended to take calcium and vitamin D supplements.
free prescriptions of certain foods -staples . eg bread, rolls ,flour mixes.
31
IBD peak incidence
adolescents - 15-17 years
32
IBD potent sign
Defaecation pain relief
33
IBD imaging Ix challenges
- unable to stay still - sedation required
34
IBD Mx care plan
With parents and school
35
Reducible hernia
can move back into place
36
Inguinal hernia examination
The child should be examined while standing.
Ascending in males, the cord is palpated.
A thickened cord relative to the contralateral side is a fair sign that a hernia may be present
Girls with clinical features of an inguinal hernia should raise suspicions about the child's genotypic sex
37
Pop quiz answers
- A x B
- B
- C
- C
- C
- B
- Reassure
- C
- C
- A
- B
38
Where is E.coli commonly found
- infected faeces
- unwashed salads or
- contaminated water
39
Travellers diarrhoea common causative bacteria
Campylobacter Jejuni
40
The main concern regarding Gastroenteritis in childre
Dehydration
41
How to assess dehydration in children
- a sunken soft spot (fontanelle) on top of their head
- sunken eyes
- few or no tears when they cry
- **Urine output** not having many wet nappies
- being drowsy or irritable
- Dry lips
- Dry mucous membrane
- Obtain weight
42
Examinations on dehydration for children
- Capillary refill: Minimal CR
- HR: Tachy
- RR: Raised RR
- BP: Low/hypotension
- Cold extremities
43
Diarrhoea Mx not clinically dehydrated
- Continue breast feeding/other milk feeds
- Encourage fluid intake
- **Discourage** **fruit juices and carbonated drinks** especially if the child is at risk of dehydration.
- Offer **oral rehydration salt** solution (ORS) as supplemental fluid to those at risk of dehydration.
44
Diarrhoea Mx **for** clinically dehydrated
- **Oral rehydration salt therapy** 50ml/kg over 4 hours
- Use IV therapy **ONLY** if shock, red flags, unable to keep fluid down
## Footnote
Consider NG tube if refuse oral
45
Sx of bacterial gastroenteritis
- High fever
- Bloody diarrhoea
- Severe abdo pain/cramps
46
Diarrhoea Ix
- **Stool MC&S:**
if Septicaemia is suspected OR
blood and/or mucus is present in the stool OR
the child is immunocompromised
- **Serum Na+, K+, Cr, Ur and glucose**
if IV fluids are going to be used.
There are symptoms/signs of hypernatraemia (jittery, increased muscle tone, hyperreflexia, convulsions, drowsiness or coma)
- **ABG**
if suspect shock
47
Normal Diarrhoea + Vomiting duration
D: 5-7 days
V: 1-2days
48
Diarrhoea complications
- Haemolytic Ureamic Syndrome (haemolytic anaemia, AKI)
- Dehydration
- Shock
- Toxic megacolon
- Reactive arthritis (bacterial gastroenteritis)
49
Common bacteria cause in diarrhoea
E. coli
50
Viral diarrhoea Sx
- Sudden onset of loose/watery stool with or without vomiting
- Abdominal pain/cramps
- **Mild** fever
- Recent contact with someone with diarrhoea or vomiting
51
How's rota / norovirus transmitted?
Faecal - Oral
52
Pyloric stenosis blood gas findings
- Hypochloric metabolic alkalosis
- **LOW** chloride, **LOW** HCl (vomiting HCl acid out)
53
Pyloric stenosis Dx
Abdo USS (visualise thicken pylorus)
54
Pyloric stenosis Tx
Ramstedt's Operation (Laparoscopic pyloromyotomy)
- Incision of the smooth muscle of the pylorus to widen the canal and allow fod to pass through into the duodenum
55
What causes the projectile vomiting in Pyloric stenosis
The peristalsis of the stomach forcing food contents on to the narrowed pylorus
56
Pyloric stenosis pathophysiology
progressive hypertrophy of the pyloric smooth muscle, causing gastric outlet obstruction
57
Hirschsprung's disease definitice Dx
Rectal Suction Biopsy
58
# 2 or more Sx
Constipation Dx criteria
1. Stool patterns: <3 stool weekly, 'ribbon poo', hard + large stool, overflow soiling
2. Sx with defecation: Straining, pain, bleeding
3. PMHx of constipation
4. Anal fissure
59
Constipation idiopathic features
- Acute illness / infection
- Dietary factors (changes to infant formula or weaning, poor diet, or insufficient fluid intake)
- Anal fissure
- Drugs (sedative antihistamine / opiates)
- Psycho factors (moving house, school, fears, accessibility to a toilet)
60
Constipation examination findings
1. **Inspect:**Normal appearance of the anus and surrounding area
2. **Palpate:**Abdo SNT with mild distention
3. **Measure:** Height, BMI (normal developmental milestones)
4. Normal motor / neuro gait, tone, power in LLs
61
Define constipation
Constipation is a decrease in the frequency of bowel movements characterized by the passing of hard stools, which may be large and associated with straining and pain
62
Appendicitis Pathophysiology
Direct luminal obstruction, usually either secondary to a faecolith (Fig. 1) or lymphoid hyperplasia, or less commonly by a malignancy. When obstructed, commensal bacteria in the appendix can multiply, resulting in acute inflammation
63
Appendicitis presentation in children
- Abdo pain
- Vomiting after abdo pain
- Diarrhoea
- Urinary Sx
- L sided abdo pain
**Typical presentation:** dull peri-umbilical pain radiating to RIF (localised + sharp)
## Footnote
Think testicular torsion / Epididymitis
64
Appendicitis examination findings
- **McBurney's point:** Rebound tenderness
- **Rovsing's sign:** Palpation of the LIF elicit pain on the RIF
65
Appendicitis Differential Diagnosis
- Gynaecological – **ovarian cyst rupture/torsion**, **ectopic pregnancy**, pelvic inflammatory disease
- Renal – ureteric stones, urinary tract infection, pyelonephritis
- Gastrointestinal – inflammatory bowel disease, **Meckel’s diverticulum**, or diverticular disease
- Urological – testicular torsion, epididymo-orchitis
- **Children**: **mesenteric adenitis**, gastroenteritis, constipation, intussusception, or urinary tract infection.
66
Appendicitis Ix
- Urinalysis: to exclude urological cause
- Pregnancy test
- Bloods: FBC, CRP, serum Beta-hCG
**Imaging:**
1st: **Abdo USS, for female and children** (minimise radiation exposure)
**Gold standard:** CT abdo (increase radiation exposure)
67
Appendicitis definitive Tx
laparoscopic appendicectomy
68
Appendicitis Complications
- **Perforation** – if left untreated the appendix can perforate and cause peritoneal contamination
- **Surgical site infection** – rates range between 3-10%, depending on degree of peritoneal contamination
- **Appendiceal mass** (as above)
- **Abscess formation**
69
What does rebound tenderness and percussion tenderness of the abdo indicative of?
Peritonism
70
Indirect Inguinal hernia
The abdo contents protrude through the **deep inguinal ring** into the inguinal canal, and through the **superficial inguinal ring** into the groin. (The protrusion occurs **laterally** to the inferior epigastric vessels)
71
Direct inguinal hernia
The abdo contents protrude through the **Hasselbach's traingle**, **medially to the inferior epigastric vessels** and through the superficial inguinal ring.
72
Define Hernia
The protrusion of an organ through the cavity wall that normally contains it
73
indirect inguinal hernia pathophysiology
The protrusion of abdo contents through the **deep inguinal ring** into the **inguinal canal**, and through the **superficial inguinal ring** into the groin. (lateral to the inf. epigatric vessels)
- This is due to **incomplete closure** of an outpouching of the peritoneum, called the the **processus vaginalis**, after the descent of testes in utero.
74
Inguinal hernia Risk factors
- Prematurity
- Male sex (male:female ratio is approximately 8:1)
- Family history
75
Inguinal hernia presentations
- Groin swelling
- Vomiting
- abdo pain
- constipation
76
Inguinal hernia examination findings
- Inguinal/inguino-scrotal mass that you **cannot ‘get above’**
- **Reducible** when lying flat
- Does not transilluminate
- +ve cough reflex
77
Inguinal hernia complications
- **Obstruction** (when bowel contents cannot pass)
- **Strangulation** (compression of the hernia has compromised the blood supply to the viscus, leading to the **bowel becoming ischaemic**
78
Most common inguinal hernia type
Indirect inguinal hernia
79
Indirect inguinal hernia Differential diagnosis
- **Hydrocele:** possible to **‘get above’** a hydrocele, **transilluminates**, non-tender
- **Varicocele:** scrotal heaviness, non-tender, **‘bag-of-worms’**sensation on palpation
80
How to differetiate **indirect/direct** inguinal hernia types on examination
1. Patient in supine position
2. Check **reducibility**
3. Mark **ASIS** and **pubic tubercle** Mid point of the inguinal ligament = deep inguinal ring
4. Occlude the deep inguinal ring
5. Ask patient to cough
**No swelling** elicited = **Indirect** inguinal herina
**Swelling** elicted = **Direct** inguinal hernia
