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Pyloric stenosis Coeliac disease Vomiting Crohn's Ulcerative colitis Abdominal pain Diarrhoea Intussusception

1
Q

What is pyloric stenosis

A

hypertrophy of the pyloric muscle causing gastric outlet obstruction

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2
Q

When does pyloric stenosis typically present?

A

at 2-7 weeks of age

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3
Q

In what gender is pyloric stenosis more common?

A

boys

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4
Q

What is a risk factor for pyloric stenosis?

A

fhx

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5
Q

What are the clinical features of pyloric stenosis?

A

vomiting - projectile
hunger after vomiting until dehydration leads to loss of interest in feeding
weight loss if delayed presentation
hypochloraemic metabolic alkalosis w low plasma sodium and potassium

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6
Q

What are the ix for pyloric stenosis?

A

test feed
gastric peristalsis
pyloric mass - feels like an olive in RUQ
US

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7
Q

What is the management of pyloric stenosis?

A

correct fluid and electrolytes - IV (0.45% saline and 5% dextrose w potassium)
Ramsteds pyloromyotomy

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8
Q

What is intussusception?

A

invagination of proximal bowel into distal segment

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9
Q

Where does intussusception most commonly occur?

A

ileocecal joint

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10
Q

What is the peak age of presentation of intussusception?

A

3m - 2yrs

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11
Q

What is a serious complication of intussusception ?

A

stretching and constriction of mesentery -> venous obstruction -> bleeding and engorgement from bowel mucosa, fluid loss and bowel perforation, peritonitis and gut necrosis

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12
Q

What are the signs/sx of intussusception ?

A
  1. paroxysms of severe colicky pain
  2. during episodes, go pale and draws up legs
  3. vomiting (can be bile stained)
  4. redcurrent jelly stool (late sign or during PR)
  5. sausage shaped mass palpable
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13
Q

What are the ix for intussusception?

A

USS - may show target like mass

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14
Q

What is the management of intussusception?

A 
Reduction by rectal air insufflation (unless peritonitis)
operative reduction (laparotomy)
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15
Q

Explain the pathophysiology of coeliac disease

A
  1. Gliadin part of gluten provokes a damaging immunological response in the proximal small intestinal mucosa
  2. There is rate of migration of enterocytes moving up the villi from the crypts but this is insufficient to compensate for cell loss from the villous tips
  3. Villi become shorter and then absent (villous atrophy)
  4. Mucosa becomes flat
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16
Q

What is the incidence of coeliac disease in children

A

1/100

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17
Q

What genes are associated w coeliac disease?

A

HLA-DQ2

HLA-DQ8

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18
Q

When does presentation of coeliac depend?

A

time child starts eating gluten

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19
Q

What is the typical presentation of coeliac disease

A 
malabsorptive syndrome:
failure to thrive, weight loss
bloating
diarrhoea 
anaemia
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20
Q

what are the clinical features of coeliac disease?

A

Highly variable including mild non-specific GI symptoms, anaemia and growth failure, arthralgia, short stature

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21
Q

What are the ix for coeliac disease

A
  1. +ve IgA tissue transglutaminase abs
  2. +ve endomysial abs
  3. small bowel biopsy at endoscopy confirms
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22
Q

When is a gluten challenge indicated in ix for coeliac disease?

A

when biopsy is doubtful
response to gluten withdrawal is doubtful
<2yrs

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23
Q

What is the management of coeliac disease?

A

gluten free diet!!

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24
Q

What foods contain gluten?

A

wheat, barley, rye

bread, cake, pasta, pizza, pies

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25
What foods don't contain gluten that are ok to eat?
rice maize soya potato
26
What conditions is coeliac disease associated w?
T1DM | Hypothyroidism
27
What is the prognosis of coeliac disease?
good if gluten free diet adhered to | increased risk of small bowel malignancy if not adhered to
28
What are common causes of abdominal pain?
gastroenteritis UTI Viral illness appendicitis
29
What is hard faeces a sign of?
constipation
30
In children of African or mediterranean decent w abdominal pain, what is important to consideR?
sickle cell disease
31
What test is important if you suspect TB in abdominal pain?
tuberculin test
32
What is pica and what is important to test for this?
eating non-food items | blood lead level and ferritin
33
What does periodic abdominal pain w vomiting pointt to?
abdo migraine
34
Abdominal pain in the presence of past UTIs points to what?
GU disease e.g renal colic
35
What are important investigations for abdominal pain?
1. urine dip - diabetes, UTI 2. AXR 3. US, FBC, CRP, renal imaging, barium studies
36
What are some rarer causes of abdominal pain?
``` Mumps Pancreatitis Diabetes Volvulus Intussusception Meckel’s diverticulum Peptic ulcer Crohns/UC Hirschsprung’s disease Henoch-Schönlein purpura Hydronephrosis ```
37
What cause of abdominal pain is important to rule out in boys?
testicular torsion
38
What causes of abdominal pain are important to consider in older girls?
menstruation | PID
39
What are some extra-abdominal causes of abdominal pain?
Upper RTI Lower lobe pneumonia Testicular torsion
40
What age is appendicitis not usually seen?
under 5yo
41
What are the sx of appendicitis?
− Anorexia − Vomiting (minimal) − Abdo pain, initially central and colicky but then localising to RIF − Flushed face with oral fetor (strong foul smell)
42
What are the signs of appendicitis?
low grade fever (37.2-38) Abdo pain aggravated by movement Persistent tenderness, guarding in RIF (McBurney's point)
43
What is McBurney's point?
Most common location of the base of the appendix where it is attached to the caecum
44
How does appendicitis in preschool children tend to present?
faecoliths seen on AXR | Rapid perforation as omentum less well developed and fails to surround appendix
45
What is a faecolith
hard discrete mass of thickened faeces
46
What are the investigations for appendicitis?
US may support diagnosis | many tests aren't useful
47
What are the complications of appendicitis?
abscess | perforation
48
What is the management of uncomplicated appendicitis?
appendicectomy
49
What is complicated appendicitis?
appendicitis + complications (perforation, appendix mass, abscess)
50
What is the management of complicated appendicitis?
fluids, IV abx, laparotomy to remove appendix
51
what age is Gastro-oesophageal reflux common and why?
infancy | inappropriate relaxation of the LOS due to functional immaturity
52
what are the risk factors for Gastro-oesophageal reflux
fluid diet horizontal posture short intra-abdominal length
53
How does Gastro-oesophageal reflux usually present?
recurrent regurgitation distress after feeds child is usually well and putting on weight
54
In who is severe gastro-oesophageal reflux common in?
cerebral palsy preterm following surgery for oesophageal atresia or diaphragmatic hernia
55
What are the complications of gastro-oesophageal reflux?
failure to thrive -severe vomiting oesophagitis - haematemesis, discomfort on feeding, anaemia pneumonia - due to recurrent aspiration
56
What are the ix for gastro-oesophageal reflux?
USUALLY CLINICAL 24h oesophageal pH monitoring to quantify degree of reflux endoscopy w oesophageal biopsy
57
What is the management of gastro-oesophageal reflux?
1. thickening agents to feeds 2. position 30 degree head up 3. avoid overfeeding 4. alginate therapy
58
What treatment may be needed in severe gastro-oesophageal reflux?
PPI - omeprazole H2 receptor antagonist - ranitidine Domperidone to enhance gastric emptying
59
what is a differential of gastro oesophageal reflux?
cows milk protein intolerance if vomitign
60
What is the treatment of gastro-oesophageal reflux that is either complicated or due to oesophageal strictures?
surgical | Nissen fundoplication
61
What is a typical presentation of toddler diarrhoea?
stools of varying consistency undigested veg in stools well and thriving w no precipitating dietary factors
62
What is the management of toddler diarrhoea?
Usually none - most grow out by 5yrs Diet adequate in fat relieves sx (slows gut transit) reduce fresh fruit juice, can exacerbate
63
What should you consider in a child failing to thrive w chronic diarrhoea?
coeliac disease | cow's milk protein intolerance
64
What should you consider in a child w chronic diarrhoea following gastroenteritis?
post-gastroenteritis syndrome and associated temporary lactose intolerance
65
what is the most common cause of chronic diarrhoea in the developed world?
cows milk protein intolerance
66
What motility disorders cause increased stool in diarrhoea?
thyrotoxicosis IBS dumping syndrome
67
What motility disorders cause decreased stool in diarrhoea?
pseudo-obstruction | intussusception
68
What are inflammatory causes of diarrhoea? (bloody)
Infectious: shigella, salmonella, rotavirus, campylobacter, Crohn's/UC, coeliac, haemolytic uraemia syndrome
69
What are causes of watery stools in diarrhoea?
Cholera c.diff ecoli
70
What is the most common cause of gastroenteritis?
rotavirus
71
What are the features of gastroenteritis?
loose or water stools (sudden) vomiting contact w person w D&V travel abroad?
72
What is a major complication of gastroenteritis?
dehydration
73
what is the treatment of gastroenteritis w no dehydration?
``` prevent dehydration continue breast feeding encourage fluids oral rehydration therapy (dioralyte) no fruit juice ```
74
What is clinical dehydration defined as?
5-10% loss of body weight
75
what is shock defined as in dehydration?
>10% loss of body weight
76
What are red flag sins of clinical dehydration
``` unwell/deteriorating altered responsiveness sunken eyes tachycardia tachypnoea reduced skin turgor ```
77
What are the ix in dehydration?
usually none | stool culture?
78
what is the rx of clinical dehydration
ORS fluid deficit replacement (50ml/kg) + maintenance fluid continue breastfeeding NG tube if vomiting or inadequate fluid intake
79
What is the rx of shock in dehydration?
IV therapy | rapid infusion of 0.9% NaCl solution
80
Explain IV therapy for rehydration
replace fluid deficit + maintenance fluids give 0.9% NaCl +/- 5% glucose maybe K+ supplementation
81
What is important to avoid when dehydrated?
fruit juices | carbonated drinks
82
How is post-gastroenteritis syndrome confirmed:
presence of non-absorbed sugar in stools - +ve clinitest result
83
What is post-gastroenteritis syndrome?
intro of normal diet making watery diarrhoea return
84
What is the management of post-gastroenteritis syndrome?
ORS for 24hr
85
What is the classical presentation of crohns?
``` growth failure delayed puberty abdo pain diarrhoea weight loss general: fever, lethargy ```
86
What are the extra-intestinal manifestations of crohns
``` oral lesions perianal skin tags uveitis arthralgia erythema nodosum ```
87
How is a diagnosis of crohns made?
raised platelets, ESR, CRP Iron deficiency anaemia low serum albumin DEFINITIVE: endoscopy w biopsy - non-caseatig epithelioid cell granulomata + fissuring, narrowing mucosal irregularities and bowel wall thickening
88
What is the pharmacological management of crohns?
1. immunosuppressants: azathioprine, methotrexate 2. Ant-TNF agents - infliximab, adalimumab 3. Supplemental enteral nutrition for growth failure
89
When is surgery necessary in crohns?
obstruction fistulae abscess formation severe localised disease unresponsive to medical treatment
90
What is the presentation of UC?
Rectal bleeding Diarrhoea Colicky pain
91
What features are more common in crohns than UC?
weight loss and growth failure
92
What are the extraintestinal manifestations of UC?
erythema nodosum | arthritis
93
What is pancolitis?
UC spread throughout entire length of colon
94
How is a diagnosis of UC made?
``` endoscopy and biopsy there is: mucosal inflammation crypt damage ulceration ```
95
What is the management of uC?
1. aminosalicylates - balsazide, mesalazine (induction and maintenance therapy) 2. systemic steroids (azathioprine) for aggressive disease
96
What is a complication of UC?
severe fulminating disease
97
What is the treatment of the serious complication of UC?
IV fluids steroids Ciclosporin (if above 2 fail)
98
What malignancy are adults w UC at risk of?
adenocarcinoma of the colon
99
What is the rx of UC confined to the rectum and sigmoid colon?
topical steroids
100
What is the difference between Crohn's and UC regarding what part of the GI tract is affected?
Crohns - ANY part, oral and perianal disease | UC - only colon, starts in rectum, extends proximally
101
What is the difference between Crohn's and UC regarding involvement
Crohns - skip lesions | UC - continuous involvement
102
What is the difference between Crohn's and UC regarding the mucosa?
Crohns has deep ulcers and fissures, cobblestone | UC - red mucosa, bleeds easily, ulcers and pseudopolyps
103
What is the difference between Crohn's and UC regarding which parts of the GI wall are inflamed?
Crohns - transmural | UC - mucosal
104
What is the difference between Crohn's and UC regarding histology?
Crohns - granulomas | UC - no granulomata, goblet cell depletion, crypt abscesses
105
What is Hirschsprung's disease?
absence of the myenteric nerve plexus (Auerbach and Meissner) in the rectum which may extend along the colon
106
How does Hirschsprung's disease present?
- no passage of meconium w/in 48h of birth and the abdomen distends - older children: constipation, abdominal distension
107
What is Hirschsprung's disease associated w?
Down's syndrome | 3x more common in males
108
How does Hirschsprung's disease present?
- no passage of meconium w/in 48h of birth and the abdomen distends - older children: constipation, abdominal distension
109
What is Hirschsprung's disease associated w?
Down's syndrome | 3x more common in males
110
What are features suggesting hyponatraemic dehydration
``` jittery movements increased muscle tone hyperreflexia convulsions drowsiness or coma ```
111
What children are at increased risk of dehydration?
``` children <1y low birthweight infants 6 or more diarrhoeal stools in past 24hrs vomited 3 or more times in past 24hrs sx of malnutrition stopped breastfeeding during illness ```
112
What is posseting?
effortless regurgitation of milk | common
113
What are the main causes of vomiting?
``` posseting between feeds GOR gastritis/gastroenteritis Overfeeding pyloric stenosis infections adverse food reactions ```
114
What causes bile-stained vomit?
intestinal obstruction | duodenal or volvulus
115
What causes haematemesis?
oesophagitis peptic ulcer oral/nasal bleeding
116
What are the causes of bloody stools?
intussusception | gastroenteritis - campylobacter or salmonella
117
What are the causes of severe dehydration/shock
severe gastroenteritis systemic infection DKA
118
What are causes of failure to thrive?
GOR | Coeliac
119
What are causes of abode distension?
obstruction
120
What is the cause of vomiting at the end of paroxysmal coughing?
whooping cough
121
what are the different causes of intestinal obstruction?
``` pyloric stenosis atresia intussusception malrotation volvulus strangulated inguinal hernia hirschsprungs adhesions foreign body ```
122
When should diarrhoea be investigated in a child?
Septicaemia is suspected. There is blood and/or mucus in the stool. The child is immunocompromised. The child has recently been abroad. The diarrhoea has not improved by day 7. There is uncertainty about the diagnosis of gastroenteritis.
123
What is Meckel's diverticulum?
vestigial remnant of the Vitelline duct
124
How does meckels diverticulum present
``` Most asymptomatic May present w: − Severe rectal bleeding − Intussusception − Volvulus − Diverticulitis ```
125
How is meckel's diverticulum diagnosed?
Technetium scan
126
What is the treatment of meckel's diverticulum?
surgical resection
127
What is the average frequency of stools in the 1st week of life?
4 a day
128
What is the average frequency of stools at 1yr age?
2 a day
129
What is average frequency of stool by 4yrs of age?
3 per day to 3 a week
130
What are causes of constipation?
``` Mostly idiopathic! Dehydration Low-fibre diet Meds e.g. opiates anal fissure potty training gone wrong hypothyroidism, hypercalcaemia Hirschsprung LDs ```
131
What are Ix for constipation?
examination - palpable abdo mass | DRE if pathological cause suspected
132
what does failure to pass meconium in the first 24hrs of life indicate?
Hirschsprung disease
133
What does failure to thrive and constipation indicate?
hypothyroidism coeliac hirschsprung
134
What does perianal fistulae, abscesses or issues indicated with constipation?
perianal crohns
135
why does constipation and diarrhoea occur at the same time?
when constipation is long standing the rectum becomes overdistended and there is a loss in the feeling/need to defecate so there is involuntary soiling as contractions of the full rectum inhibit the internal sphincter leading to overflow
136
Give then management of constipation
1. macrogol laxative - movicol 2. stimulant laxative (Senna) 3. +/- osmotic laxative - lactulose 4. enema or manual evacuation
137
When should constipation be suspected?
2 or more of the following clinical features: 1. fewer than 3 complete stools per week 2. hard, large stool 3. 'rabbit droppings' stool 4. overflow soiling in older 1yrs
138
when should faecal impaction be suspected?
1. hx of severe sx of constiopation 2. overflow soiling 3. faecal mass palpable on abdominal examination
139
What are behavioural interventions for constipation?
scheduled toileting bowel habit diary reward systems
140
what are complications of idiopathic constipation?
``` anal fissure haemorrhoids rectal prolapse megarectum faecal impaction and soiling volvulus distress ```
141
give red flags of constipation that indicate hirschsprungs
sx of constipation from brith or first few weeks of life delay in passing meconium for more Han 48hrs after birth abdo distension w vomiting FHx
142
Give a red flag of constipation that may indicate CF
Delay in passing meconium for more than 48h after birth
143
what does ribbon stool pattern in constipation indicate?
anal sphincter stenosis
144
give red flag sx of constipation that hint at neurological problems
Leg weakness/ motor delay - spinal cord abnormality | abnormalities in gluteal muscles
145
Give amber flags of constipation
``` faltered growth (systemic) constipation triggered by intro of cows milk poss child maltreatment ```

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