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GI Flashcards

1
Q

What is gastro-enteritis?

A

Diarrhoea that occurs when intestinal fluid output overwhelms the absorptive capacity of the GI tract

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2
Q

Why does diarrhoea happen?

A

(1) Damage to the villous brush border of the intestine, causing malabsorption of intestinal contents and leading to an osmotic diarrhoea (CF, lactose intolerance, IBD, coeliac)
(2) The release of toxins that bind to specific enterocyte receptors and cause the release of chloride ions into the intestinal lumen, leading to secretory diarrhoea (infection, post-antibiotics)

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3
Q

What is oral rehydration therapy

A

1:1 ratio of sodium and glucose

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4
Q

Difference between watery stools, blood/mucus and steatorrhoea

A

Frequent, watery stools are more consistent with viral gastroenteritis, while stools with blood or mucous are indicative of a bacterial, steatorrhoea in coeliac, CF

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5
Q

Does the time scale of diarrhoea give a clue to its pathology?

A

Yes

A long duration of diarrhoea (>14 days) is more consistent with a parasitic or noninfectious cause of diarrhoea

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6
Q

Causes of vomiting in children?

A

GI: GORD, gastro-enteritis, constipation, overfeeding
Allergy/intolerance
Toxic ingestion
Obstructive: pyloric stenosis, intussessption, intestinal malrotation
Vestibular: Migraine/motion sick/labyrinthitis
CNS: Concussion, meningitis, raised ICP
Metabolic: DKA, Addison’s, CAH
Behavioural: Bulemia nervosa

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7
Q

Differential to gastro-enteritis

A

Hepatitis, IBD, appendicitis, DKA, lactose intolerance, pancreatitis, pyelonephritis, UTI, intussusception, pyloric stenosis, septic shock, toxic ingestion, overflow constipation

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8
Q

Common bacterial causes of gastro-enteritis

A

Enterotoxic E. Coli, Campylobacter, Salmonella, C. diff, Shigella

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9
Q

Common viral causes of gastro-enteritis

A

Rotavirus, noroviruses, enteric adenovirus

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10
Q

Common parasitic causes of gastro-enteritis

A

Giardia, cryptosporidium

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11
Q

When would you send a stool sample in suspected gastro-enteritis

A

If:
C. diff is suspected
Blood in stool
Parasites likely

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12
Q

Difference between reflux and GORD disease?

A

Reflux is relaxation of the lower oesophageal sphincter

GORD disease is reflux oesophagitis • Barrett’s oesophagus • Respiratory complications • Failure to thrive

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13
Q

Symptoms of GORD

A
  • Vomiting
  • Irritability
  • Coughing after feeds.
  • Sandhifer syndrome
  • Failure to thrive
  • Refusal to feed
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14
Q

What is Sandhifer syndrome?

A
  • Reflux causes baby to extend and spasm until acid returns to stomach (spasmodic torsional dystonia)
  • Accurate Hx needed to distinguish this from infantile spasms
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15
Q

Treatment of infant GORD?

A

Tilting bed and not lying infant down after feeds
Thickening the milk
Adding gaviscon into the milk which thickens and decreases acidity
Decrease volume and increase freq of feeds Omeprazole

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16
Q

Red flags of GORD

A 
Forceful and frequent 
<2months old
Bile stained
Haematemesis
Onset >6 months or persists >1yr
Blood in stool
Abdominal distension/mass/tenderness, Systemic unwell
Faltering growth or weight loss
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17
Q

How do you test for a food allergy?

A

Response to elimination for 3-4 weeks AND reintroduction

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18
Q

Symptoms of a food allergy in infants

A 
GORD
Loose /frequent stools
Blood/mucous in stools
Abdominal pain
Infantile colic
Food refusal/aversion
Constipation (straining on a soft stool)
Perianal redness
Pallor and tiredness
Faltering growth
Eczema
-> if CHRONIC
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19
Q

What is lactose intolerance

A

Inability to digest lactose into its constituents, glucose and galactose, secondary to low levels of lactase enzyme in the brush border of the duodenum

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20
Q

Symptoms of lactose intolerance

A

Loose stools, abdominal bloating and pain, flatulence, nausea, and borborygmi (stomach rumbles)

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21
Q

Cause of symptoms in lactose intolerance

A

The combined increase in faecal water, intestinal transit, and generated hydrogen gas accounts for the wide range of gastrointestinal symptoms

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22
Q

What is secondary lactose intolerance?

A

Damage of the brush border

Usually after acute illness (eg. giardiasis, gastroenteritis, Crohn’s, HIV enteropathy, Chemo)

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23
Q

What are risk factors for constipation?

A

LAC (looked after children), physical disability, toddlers, Down’s and autism

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24
Q

Red flags in constipation

A
  • Constipation from birth (hischsprung? congenital defect in GI system)
  • Previously unknown leg weakness/delayed gross motor (spinal cord?)
  • Abdominal distension with vomiting (bowel obstruction?)
  • Faltering growth (CF, coeliac)
  • Non responsive to treatment within 3 months
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25
Q

What is hirschsprung disease?

A
  • Functional obstruction of the gut due to lack of innervation and ganglia in the distal colon
  • -> increased smooth muscle tone and intrinsic enteric relaxing impulses are lost
  • Developmental disorder, usually diagnosed in newborn period if there is a failure of passage of meconium in the first 24-48hrs after birth & distended abdomen.
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26
Q

How do you diagnose hischsprung disease?

A

Diagnosed with contrast enema and full thickness rectal biopsy

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27
Q

How do you treat hischsprung disease?

A

Removal of aganglionic bowel using intestinal pull through (Soave)

28
Q

Signs of a congenital pyloric stenosis?

A
  • Presents in 1st 3-4 weeks of life with projectile, non bilious vomiting after feeds
  • Baby is malnourished and always hungry
  • Pyloric mass felt in RUQ in test feed
29
Q

Treatment of pyloric stenosis

A

Correct alkalosis
Stabilise ions
Hydrate
Pyloromyotomy

30
Q

What is intussusception? What happens if untreated?

A

Small bowel telescopes (swallowing itself by invagination)

Untreated-> necrotic bowel

31
Q

Signs and symptoms of intussusception?

A
  • Presents at any age (esp 5-12months)
  • Intermittent inconsolable crying with drawing of legs up +- bilious vomiting
  • May have ‘redcurrant jam’ blood in nappy
  • Sausage shaped abdominal mass may be felt
32
Q

What is seen on USS in intussusception?

A

Target sign

33
Q

Treatment of intussusception

A

Reduction by air enema/balloon catheter under USS
Fluid resuscitation
Analgesia
Antibiotics

34
Q

Risk factors for intussusception?

A

More common in CF, HSP, lymphoma

35
Q

What happens in midgut malrotation? Signs and symptoms?

A
  • If gut is malrotated during embryonic development it is prone to undergo volvulus upon the mesentery. Superior mesenteric artery completely cut off.
  • Usually in neonatal period: green bilious vomit, distension, rectal bleeding
36
Q

What is coeliac disease?

A

• IgA autoimmune systemic disorder of genetically susceptible individuals (eg HLA-DQ2-8)
• Triggered and maintained by gluten
1/100 children

37
Q

Signs of coeliac disease?

A 
Largely distended abdomen,
Weight loss/skeletal appearance after weening
Flat buttocks
Failure to thrive
Abnormal stools
38
Q

How is coeliac diagnosed?

A

Diagnosis by serology (IgA, EMA, TransGlutaminase) and histology (flattening of cilia, inflammation)
Must be eating at least 2 portions a day of gluten for 4 months for these features to be seen.
Diagnosis can also be a really high IgA and genetic testing.

39
Q

Treatment of coeliac?

A

Gluten free diet for life
(Wheat, rye, barley)
Dietetic support

40
Q

What is associated with coeliac disease?

A

Associated with other autoimmune disease (T1DM, thyroid disease)
Secondary lactose intolerance

41
Q

Inflammatory bowel disease signs and symptoms

A

Abdo pain, poor growth, delayed puberty, diarrhoea, rectal bleeding, pyoderma gangrenosum

42
Q

Crohn’s signs and symptoms

A

Oral ulcers, anorexia, anal fissures/fistulae, weight loss:

transmural

43
Q

Ulcerative colitis signs and symptoms

A

Passage of mucus, urgency, bloody diarrhoea

Diffuse mucosal, uniform, continuous inflammation

44
Q

Complications of Crohn’s disease

A

Intestinal strictures
Abscesses in the wall of the intestine or adjacent structures
Fistulae
Anaemia
Malnutrition
Colorectal and small bowel cancers
Growth failure and delayed puberty in children

45
Q

Extra-intestinal manifestations of Crohn’s

A

Arthritis and abnormalities of the joints, eyes, liver and skin
Secondary osteoporosis

46
Q

Treatment of Crohn’s

A

To induce remission:
Oral steroids/budesonide
Aminosalicylates (sulfasalazine and mesalazine) are less effective
Azathioprine or mercaptopurine can be added
MAB: adalimumab and infliximab if severe

Maintenance:
Azathioprine or mercaptopurine

Loperamide hydrochloride or codeine phosphate for diarrhoea

47
Q

Ulcerative colitis treatment

A

Chronic diarrhoea:
loperamide hydrochloride or codeine phosphate

Rectal aminosalicylate (mesalazine or sulfasalazine
Add oral prednisolone if not improved
MABs if not improved

Acute severe:
IV ciclosporin/infliximab
IV hydrocortisone

48
Q

Treatment of C.diff colitis

A

Metronidazole

Vancomycin

49
Q

First line treatment in mod/severe constipation

A

Macrogol (eg laxido) osmotic laxative

50
Q

What is the diagnosis of tinkling bowel sounds, swelling in testicle, cannot get above, doesn’t transilluminate

A

An incarcerated inguinal hernia

Due to processus vaginalis (outpouching of peritoneum)

51
Q

What are the 2 main types of malabsorption?

A

Due to lack of enzymes for breakdown of food (eg pancreatic insufficiency)
Due to disruption of luminal border of gut

52
Q

What can go wrong in the luminal phase to cause malabsorption?

A 
Cofactor deficiency (eg pernicious anaemia)
Lipid solubilisation (bile salt synthesis/cholestasis/bile salt loss)
Defective nutrient hydrolysis (pancreatic enzymes, lipase activation, rapid transit of food)
53
Q

Signs of malabsorption

A
  • Weight loss/Failure to thrive
  • Abnormal diarrhoea/steatorrhoea/flatulence
  • Nutritional deficiency
54
Q

Risk factors for malnutrition

A

Delayed or problematic progression of solids
Early feeding difficulties (GORD, tube feeding)
Poor appetite
Dental problems
Parents cultural attitude
Behavioural difficulties /rigid parenting skills
Parental (eg post-natal depression)

55
Q

What can go wrong in the mucosal phase to cause malabsorption?

A

Extensive mucosal loss (resection/infarction)
Diffuse mucosal disease (coeliac, Crohn’s)
Disease of enterocytes

56
Q

What can go wrong in the transport phase to cause malabsorption?

A

Vascular (vasculitis, atheroma)

Lymphatic drainage

57
Q

Most common cause of gastroenteritis in UK

A

Rotavirus

58
Q

What metabolic issue can cause constipation?

A

Hypothyroidism

59
Q

Name 4 pathogens that can cause bloody diarrhoea

A

Shigella, E.coli, salmonella, campylobacter

60
Q

Name 4 signs of chronic liver disease in children

A

Bruising
Clubbing
Splenomegaly
Encephalopathy

61
Q

Difference between infant and adult inguinal hernias

A

Infant (always indirect, due to patent processus vaginalis)

Adult (indirect or direct, due to weakness in muscle of inguinal canal

62
Q

Definition of hernia

A

Protrusion of a viscus or part of a viscus through the walls of its containing cavity into an abnormal position

63
Q

Describe formation of congenital hernia

A

Patent processus vaginalis
Processus vaginalis should obliterate following descent of the testes.
If it stays patent it may fill with
- Fluid → hydrocele
- Bowel/omentum → indirect inguinal hernia

64
Q

Describe an indirect inguinal hernia

A

 Emerge through deep ring, inguinal canal and superficial ring
Intestinal loop within spermatic cord
 Same 3 coverings as cord and descend into the scrotum
 Can strangulate
Herniating bowel passes lateral to inferior epigastric vessels
Above and medial to pubic tubercle

65
Q

Describe direct inguinal hernia

A

Acquired, older people
Emerge through Hesselbach’s triangle, defect in posterior wall of inguinal canal (peritoneum and transversalis fascia)
Herniating bowel passes medial to inferior epigastric vessels
Rarely descend into scrotum
Rarely strangulate
Above and medial to pubic tubercle

66
Q

Borders of hesselbach triangle

A 
Inguinal ligament (inferiorly)
Inferior epigastric vessels (superio-laterally)
Rectus abdominis muscle (medially)
67
Q

Where are femoral hernias?

A

Below inguinal ligament
In femoral canal
Below and lateral to pubic tubercle
Medial to sartorius and femoral nerve and artery

Paeds (14 decks)

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