GI Flashcards
What is gastroenteritis?
sudden onset of diarrhoea (acute) caused by most commonly viruses e.g. rotavirus, norovirus, adenovirus but also bacteria e.g. salmonella, shigella, campylobacter, E. coli and protozoal infection e.g. giardia, cryptosporidium.
How is gastroenteritis managed?
Stool sample IF immunocompromised, bloody/mucus in stool, suspect/ confirmed sepsis.
Child w/o clinical dehydration: 1. continue breast feeding; 2. Oral Rehydration Solution (hypotonic); 3. avoid cow’s milk, fruit+ carbonated drinks temporarily 4. Encourage oral intake.
Child w clinical dehydration: AS ABOVE +
1. 50ml/kg for fluid deficit replacement over 4h + normal intake 2. consider NGT for ORS if unable to take orally 5. Frequent reassessment.
Child w shock, red flags despite oral therapy, vomitting NGT/Oral ORS:
1. IV Fluid isotonic solution, such as 0.9% sodium chloride, or 0.9% sodium chloride with 5% glucose, for deficit replacement and maintenance
2. for suspected or confirmed shock, add 100 ml/kg for fluid deficit replacement to maintenance fluid requirements, if not go for 50ml/kg and monitor response.
3. Monitor plasma: sodium, potassium, urea, creatinine and glucose and alter rehydration if needed.
Following rehydration, reintroduce usual foods, continue breast milk. Public health things: no sharing towels, hand washing, not attending School for 48h after last diarrhoea, no swimming 2w after last diarrhoea.
What are the clinical signs of dehydration? What are the RED FLAGS?
- Early- Dry Mucus Memb (Reduced Ach and therefore no saliva prod) but unreliable bc can be due to mouth breathing due to snotty nose or lots of crying
- Late- sunken eyes (loss of fluid subcut tissue. dried out fat pad behind orbit), reduced skin turgor (loss of fluid subcut tissue + lost elasticity of collagen), depressed fontanelle (CSF production affected - v late sign), Drowsy, decreased urine output, weak peripheral pulses.
- Best- Sudden weight loss v reliable.
RED FLAGS:
- Tachycardia (if sustained when asleep- true indicator, otherwise child could be angry/ agitated),
- Hypotensive (indicates decompensation- really BAD sign particularly in younger kids),
- Peripherally shut down- delayed cap refill, cool peripheries
What are key elements for diarrhoea history?
Basics: Duration, Onset, Gradient (is it getting worse), Associated Factors e.g. fever, Relieving/Exacerbating factors, Severity (how many dirty nappies in last 24h)?
Specific to diarrhoea: Fewer wet nappies (reduced urine output?), vomitting- freq, duration, blood?, feeding (breast, formula, meals last 24h)- freq + (duration- not as accurate) CONVERT milk to ml/kg/day, consistency of diarrhoea (porridge/ gravy), Abdo pain - irritability, blood in nappy- in stool or nappy rash, antibiotic/ recent travel recently, affected family?, parental occupation- notifiable diseases.
Remember vomiting (>3 x in 24h), lots of dirty nappies >6 in 24h, under 6m, low birth weight, not feeding well.
What is meant by irritability?
- High pitched crying
- Almost continuous
- Inconsolable
Result of Pain
What do you examine in a patient presenting with diarrhoea?
- Observation - look for clinical signs of dehydration, buttock wasting, distension (undigested fats - fermented- gas prod), anus- fissures/ fistula (Crohn’s in older child), nappy rash visible?
- Weight, Temp, NO PR.
what is the ddx for chronic diarrhoea?
Malabsorption: Intolerances e.g. Coeliac, Cow's milk intolerance, CF, Older Kids- IBD. protozoal infection (giardia, cryptosporidium)
What is the pathophysiology of diarrhoea?
- Infection attacks cells of the brush border.
- Reduced enzyme capacity and food is consequently not digested properly.
- undigested food Is osmotically active and holds onto water.
- Watery diarrhoea
- Undigested fats (peptides) reach bacteria in large intestine which they ferment and produce gas causing distension + abdo pain
- smelly + floating diarrhoea due to fermentation process + fat presence in diarrhoea.
What is Hirschprung’s disease?
partial/ complete colonic obstruction due to absence of intramural ganglion cells (in myenteric plexus) leading to tonic contraction of the lumen and “functional” obstruction. Always located distally but the length of affected bowel is variable.
presents with delayed passage of meconium + enterocolitis episodes (abdominal distension, explosive diarrhea, vomiting, fever, lethargy, rectal bleeding, and shock). rectal biopsy. Management: removal of non functional bowel and restore continuity prior to potty training age.
What are the benefits of breastfeeding?
GI, LRTI, OM are reduced. NEC in preterms is reduced. Reduced incidence DM, HT, Obesity in later life. Can facilitate bonding between baby and mom. Colostrum has high content protein + Ig’s and is first expressed before milk comes in.
ideal form of nutrition for baby until ~4-6 months.
Contents of milk: IgA that coats mucosal surfaces, bactericidal enzymes preventing e.coli + promoting lactobacillus growth. easily digestible due to protein content (increased whey: casein) + breast milk lipase, good bioavailability of Iron, lymphocytes, macrophages, high Ca content, low renal solute load.
what are the disadvantages of breastfeeding?
not adequate beyond 6months without supp. for weight gain + avoid rickets
transmission of infections- HIV, CMV, Hep B
Breast milk jaundice (self-resolves)
transmission of drugs
Emotional upset if cannot establish
What is the difference between specialist formulas available?
hydrolysed feed (extensively)- used in IgE mediated cow’s milk protein allergy and cow’s milk protein intolerance +/- fat malabsorption
semi-hydrolysed- atopy
whole protein- normal kids
High energy- pre-term, CF, failure to thrive
carob based thickener used in GOR
what is the recommended intake for an infant in the first year of life? How frequently should newborns be feeding? How many cals are there in breast milk/ formula milk/ 100ml?
150 mL - 200 mL/kg/day for prems.
150ml/kg/day up to 6 m.
Newborn babies will need to feed two to three-hourly during the day and night; this will graduate to four-hourly feeds at around six weeks of age for most babies.
after 6m, a volume of 600 mL/day should be maintained, in addition to solid food.
70kcal/ 100ml.
what is the ddx for faltering growth? What is the definition of faltering growth?
Sustained drop down two centile spaces. Remember to use correct chart for pre-term etc.
1/ inadequate intake: feeding problems
2/ malabsorption: CF, coeliac, cow’s milk protein allergy
3/ inadequate retention: vomitting, severe GOR
4/ increased requirements (chronic disease): Hyperthyroid, CHD, CKD, CF
failure to utilise nutrients: IUGR, congenital infection, chr abnormalities Down’s
What examinations should be done in FTT?
Distension (better to assess laid down bc rectus sheath is poorly developed in young kids therefore stretches when stood up)
Shifting Dullness- distinguish fluid from flatus
Subcut loss- thin arm + leg circumference
Buttock wasting- due to protein breakdown for energy source
Miserable
