GI Flashcards
Paeds Common GI clinical presentations
- Pain
- Vomiting (freq., content, ?blood)
- Lack of appetite
- Bloating
Infectious Gastroenteritis
an infection of the gastrointestinal tract by a virus / bacteria
Paeds dehydration assessment
- ?Active
- ?chatty
- ?Playful
- ?Smiley
- Skin tugor
- RR
- HR
- O2 sat.
Paeds diarrhoea without dehydration
- Obtain weight
- Electrolyte replacements
- push fluids
- Monitor urine output
When to admit to hosp with diarrhoea
- 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)
Constipation Adbo examination
- Abdo examinations
- Height
- Weight
- Check anus region
Abdo examination findings
- Firm stool on palpation
- Tenderness
- distention
Paeds constipation aetiology
- Functional (95%)
- Organic causes (5%)
Constipation organic causes
-
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
Meconium
1st stool should pass within the first 24 hours after birth
Hirschprungsdisease
Abscence of ganglion cell in the megacolon
Constipation Mx
osmoticLifestyle: High fibre, high fluid, activities
1st line: Macrogol (osmotic laxative)
if not improving in 2/52
- add in senna (stimulant) +/- lactulose (osmotic)
Chronic constipation duration
8 wks or more
Constipation peak incidence
2-3 years
Constipation RED FLAGS
- 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
Constipation Amber FLAGS
- Evidence of faltering growth, developmental delay, or concerns about wellbeing
Can treat constipation in primary care whilst waiting for assesment
Refer to paeds
Constipation WITH faecal imapction
- Macrogol disimapction regimen
- if not improving post 2/52 add senna
- if macrogol not tolerated subs with stimulant laxative +/- lactulose
Breastfed infants stool
- watery, loose, poo frequently (6-8 times daily)
Paeds gastroenteritis common causative virus
Norovirus
Rotavirus (vaccinated against)
Diarrhoea Hx taking
- up to date with vaccine??
Diarrhoea advice for social setting
- 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
Gastro-oesophogeal reflux – Risk Factors
- Premature birth.
- Parental history of heartburn or acid regurgitation.
- Hiatus hernia.
- History of congenital diaphragmatic hernia
- History of congenital oesophageal atresia
- Neurodisability.
Gastro-oesophogeal reflux – Management
- 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
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
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
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.
Pyloric stenosis examination findings
- olive shape mass at RUQ (hypertrophic pylorus)
Coeliac-Presentation
Presentation is varied EASILY MISSED and ranges from
Diarrhoea
abdominal pains
failure to thrive/faltering growth
iron-deficiency anaemia
Tiredness
Coeliac potent sign
Failure to thrive - weight and height
Risk factors for coeliac disease
Family hx of coeliac
Autoimmune disorders
type 1 DM
thyroid disease
Downs syndrome
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.
IBD peak incidence
adolescents - 15-17 years
IBD potent sign
Defaecation pain relief
IBD imaging Ix challenges
- unable to stay still - sedation required
IBD Mx care plan
With parents and school
Reducible hernia
can move back into place
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
Pop quiz answers
- A x B
- B
- C
- C
- C
- B
- Reassure
- C
- C
- A
- B
Where is E.coli commonly found
- infected faeces
- unwashed salads or
- contaminated water
Travellers diarrhoea common causative bacteria
Campylobacter Jejuni
The main concern regarding Gastroenteritis in childre
Dehydration
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
Examinations on dehydration for children
- Capillary refill: Minimal CR
- HR: Tachy
- RR: Raised RR
- BP: Low/hypotension
- Cold extremities
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.
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
Consider NG tube if refuse oral
Sx of bacterial gastroenteritis
- High fever
- Bloody diarrhoea
- Severe abdo pain/cramps
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
Normal Diarrhoea + Vomiting duration
D: 5-7 days
V: 1-2days
Diarrhoea complications
- Haemolytic Ureamic Syndrome (haemolytic anaemia, AKI)
- Dehydration
- Shock
- Toxic megacolon
- Reactive arthritis (bacterial gastroenteritis)
Common bacteria cause in diarrhoea
E. coli
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
How’s rota / norovirus transmitted?
Faecal - Oral
Pyloric stenosis blood gas findings
- Hypochloric metabolic alkalosis
- LOW chloride, LOW HCl (vomiting HCl acid out)
Pyloric stenosis Dx
Abdo USS (visualise thicken pylorus)
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
What causes the projectile vomiting in Pyloric stenosis
The peristalsis of the stomach forcing food contents on to the narrowed pylorus
Pyloric stenosis pathophysiology
progressive hypertrophy of the pyloric smooth muscle, causing gastric outlet obstruction
Hirschsprung’s disease definitice Dx
Rectal Suction Biopsy
2 or more Sx
Constipation Dx criteria
- Stool patterns: <3 stool weekly, ‘ribbon poo’, hard + large stool, overflow soiling
- Sx with defecation: Straining, pain, bleeding
- PMHx of constipation
- Anal fissure
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)
Constipation examination findings
- Inspect:Normal appearance of the anus and surrounding area
- Palpate:Abdo SNT with mild distention
- Measure: Height, BMI (normal developmental milestones)
- Normal motor / neuro gait, tone, power in LLs
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
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
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)
Think testicular torsion / Epididymitis
Appendicitis examination findings
- McBurney’s point: Rebound tenderness
- Rovsing’s sign: Palpation of the LIF elicit pain on the RIF
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.
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)
Appendicitis definitive Tx
laparoscopic appendicectomy
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
What does rebound tenderness and percussion tenderness of the abdo indicative of?
Peritonism
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)
Direct inguinal hernia
The abdo contents protrude through the Hasselbach’s traingle, medially to the inferior epigastric vessels and through the superficial inguinal ring.
Define Hernia
The protrusion of an organ through the cavity wall that normally contains it
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.
Inguinal hernia Risk factors
- Prematurity
- Male sex (male:female ratio is approximately 8:1)
- Family history
Inguinal hernia presentations
- Groin swelling
- Vomiting
- abdo pain
- constipation
Inguinal hernia examination findings
- Inguinal/inguino-scrotal mass that you cannot ‘get above’
- Reducible when lying flat
- Does not transilluminate
- +ve cough reflex
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
Most common inguinal hernia type
Indirect inguinal hernia
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
How to differetiate indirect/direct inguinal hernia types on examination
- Patient in supine position
- Check reducibility
- Mark ASIS and pubic tubercle Mid point of the inguinal ligament = deep inguinal ring
- Occlude the deep inguinal ring
- Ask patient to cough
No swelling elicited = Indirect inguinal herina
Swelling elicted = Direct inguinal hernia
