GI Flashcards by Lisa McCulloch

what anatomical and physiological features in children can contribute to GORD?

short narrow oesophagus
delayed gastric emptying
spending significant periods lying down
shorter oesophageal sphincter

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what are risk factors for GORD?

prematurity 
obesity 
hiatus hernia 
history of congenital of diaphragmatic hernia or oesophageal atresia 
neurodisability (cerebral palsy)

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what are DD for GORD?

pyloric stenosis
intestinal obstruction 
upper GI bleed 
sepsis 
raised ICP 
chronic diarrhoea 
UTI
cows milk protein allergy

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what is the history a pt may present with GORD?

distressed behaviour
unexplained feeding difficulties
chronic cough
faltering growth

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what should be asked for a full feeding history ?

check position, attachment, technique, duration, frequency and type of milk

calculate volume of milk given (may be over fed)

frequency and volumes of vomits

relationship of symptoms to feeds

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what is the management of GORD if infant is well?

if infant is well = reassurance

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what is the management of GORD if infant is formula fed?

1 = ensure infant isn’t over fed

2 = decrease feed volume by increasing frequency

3 = use feed thickener

4 = stop thickener and start alginate added to formula

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if symptoms persist for GORD after feed thickener has been used what medication can be used?

proton pump inhibitor or histamine antagonist (eg. Omeprazole or ranitidine)

refer to paediatrics

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what % of GORD will spontaneously resolve within the first year?

90%

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what are complications of GORD ?

reflux oesophagitis 
recurrent aspiration pneumonia 
recurrent acute otitis media 
dental erosion 
apnoea

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what % of infants experience regurgitation?

40%

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what volume should an infant be feed per day?

150ml/kg/day

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what genetic factors are associated with coeliac disease?

HLA DQ2/8

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what antibodies are present in coeliac disease?

anti tissue transglutaminase

anti endomysial

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what conditions are associated with coeliac disease?

autoimmune conditions

downs syndrome

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what are the 5 clinical forms of coeliac ?

classical - malabsorption, failure to thrive, loose stool, steatorrhoea, anorexia

atypical - no intestinal symptoms, associated with osteoporosis, peripheral neuropathy, anaemia and infertility

latent - presence of predisposing gene

silent - damaged intestinal mucosa but no clinical symptoms

potential - normal mucosa but + autoimmune serology

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state some extra intestinal features of coeliac ?

dermatitis herpetiformis 
dental enamel hypoplasia 
osteoporosis 
delayed puberty (not precocious puberty)
short stature 
Fe anaemia 
arthritis

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what are some DD for coeliac ?

tropical sprue 
CF
IBD
post gastroenteritis 
eosinophilic enteritis

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what is the gold standard investigation for coeliac ?

duodenal biopsy

what classification is used for duodenal biopsy ?

Marsh classification

state the Marsh classification for coeliac disease ?

0 = normal 
1 = increased intraepithelial lymphocytes 
2 = increased inflammatory cells and crypt hyperplasia 
3 = increased intraepithelial lymphocytes, inflammatory cells and crypt hyperplasia and villous atrophy

what mediates cows milk protein allergy ?

two types …

immune mediated allergic response to casein and whey

IgE mediated - Type 1 hypersensitivity

Non IgE mediated - involves T cell activation

what happens during IgE mediated cows milk protein allergy?

CD4+ TH2 cells stimulate B cells to produce IgE antibodies against cow’s milk protein which trigger the release of of histamine and other cytokines from mast cells and basophils.

what are risk factors for cows milk protein allergy ?

history of atopy

FHx of atopy

does IgE or non IgE CMP allergy begin quicker ?

IgE mediated is an acute onset | Non IgE manifests over 48hrs

what % of children are affected by CMPA?

what skin signs are associated with IgE mediated CMPA?

pruritus erythema acute urticaria acute angio-oedema

what skin signs are associated with non-IgE mediated CMPA?

pruritus erythema atopic eczema

what GI signs are associated with IgE mediated CMPA?

oral pruritus nausea colicky abdo pain V/D

what GI signs are associated with non-IgE mediated CMPA?

``` GORD blood/mucus in stool food refusal constipation perianal redness pallor and tiredness ```

what are DD of CMPA?

``` UTI pancreatic insufficiency (CF) coeliac, IBD, GE Meckels diverticulum food intolerance ```

when should investigations be done for CMPA?

when the diagnosis is unclear

what investigations can be done for CMPA?

specific IgE antibodies blood test Non IgE mediated CMPA is clinically diagnosed

what is the management of CMPA?

avoid cows milk (including mothers diet if breast feeding) - re evaluation in 6months monitor growth replace with hypoallergenic formula - extensively hydrolysed formula (casein and whey are broken down into smaller peptides) - amino acid formula soya based formulas aren't recommended in infants <6months due to weak oestrogenic effect of isoflavones and absorption of minerals and trace elements may be inhibited by phytate

what virus and bacteria most commonly causes gastroenteritis in children ?

rotavirus and campylobacter

when is the rotavirus vaccine given ?

8 and 12 weeks

what type of virus is norovirus ?

single stranded RNA virus

what virus is the most common cause of gastroenteritis in all ages?

norovirus

what age groups are commonly affected by gastroenteritis caused by adenovirus?

<2yrs

what investigations can be done for gastroenteritis ?

stool sample if - septicaemia is suspected - blood/mucus in stool - immunocompromised measure acid-base status and chloride concentration if shock is suspected

when should blood tests be done to measure Na+, K+, Cr, Ur and glucose?

if - IV fluids are going to be used - symptoms of hypernatraemia (increased tone, hyperreflexia, convulsions, coma)

what is the management of gastroenteritis ?

encourage fluid intake/offer ORS (50ml/kg/4hrs + maintenance fluids) IV fluids if shock is suspected or persistently vomiting if child is refusing fluids then consider NG tube

how do you calculate maintenance fluid for children?

0-10kg = 100ml/kg/day 10-20kg = 1000ml + 50ml/kg/day >20kg = 1500ml + 20ml/kg/day

when can the child with gastroenteritis return to school?

48hrs after the last episode has passed | and shouldn't swim for 2 weeks after last episode

what are complications of gastroenteritis ?

HUS - causes acute renal failure and haemolytic anaemia toxic megacolon - complication of rotavirus acquired lactose intolerance ``` reactive complications (arthritis, carditis, urticaria, erythema nudism, conjunctivitis) - reiters syndrome (can't see, pee or climb a tree) ```