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GI Flashcards

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
Q

What foods don’t contain gluten that are ok to eat?

A

rice
maize
soya
potato

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26
Q

What conditions is coeliac disease associated w?

A

T1DM

Hypothyroidism

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27
Q

What is the prognosis of coeliac disease?

A

good if gluten free diet adhered to

increased risk of small bowel malignancy if not adhered to

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28
Q

What are common causes of abdominal pain?

A

gastroenteritis
UTI
Viral illness
appendicitis

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29
Q

What is hard faeces a sign of?

A

constipation

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30
Q

In children of African or mediterranean decent w abdominal pain, what is important to consideR?

A

sickle cell disease

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31
Q

What test is important if you suspect TB in abdominal pain?

A

tuberculin test

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32
Q

What is pica and what is important to test for this?

A

eating non-food items

blood lead level and ferritin

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33
Q

What does periodic abdominal pain w vomiting pointt to?

A

abdo migraine

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34
Q

Abdominal pain in the presence of past UTIs points to what?

A

GU disease e.g renal colic

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35
Q

What are important investigations for abdominal pain?

A
  1. urine dip - diabetes, UTI
  2. AXR
  3. US, FBC, CRP, renal imaging, barium studies
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36
Q

What are some rarer causes of abdominal pain?

A 
Mumps
Pancreatitis 
Diabetes
Volvulus
Intussusception
Meckel’s diverticulum
Peptic ulcer
Crohns/UC
Hirschsprung’s disease
Henoch-Schönlein purpura 
Hydronephrosis
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37
Q

What cause of abdominal pain is important to rule out in boys?

A

testicular torsion

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38
Q

What causes of abdominal pain are important to consider in older girls?

A

menstruation

PID

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39
Q

What are some extra-abdominal causes of abdominal pain?

A

Upper RTI
Lower lobe pneumonia
Testicular torsion

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40
Q

What age is appendicitis not usually seen?

A

under 5yo

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41
Q

What are the sx of appendicitis?

A

− Anorexia
− Vomiting (minimal)
− Abdo pain, initially central and colicky but then localising to RIF
− Flushed face with oral fetor (strong foul smell)

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42
Q

What are the signs of appendicitis?

A

low grade fever (37.2-38)
Abdo pain aggravated by movement
Persistent tenderness, guarding in RIF (McBurney’s point)

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43
Q

What is McBurney’s point?

A

Most common location of the base of the appendix where it is attached to the caecum

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44
Q

How does appendicitis in preschool children tend to present?

A

faecoliths seen on AXR

Rapid perforation as omentum less well developed and fails to surround appendix

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45
Q

What is a faecolith

A

hard discrete mass of thickened faeces

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46
Q

What are the investigations for appendicitis?

A

US may support diagnosis

many tests aren’t useful

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47
Q

What are the complications of appendicitis?

A

abscess

perforation

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48
Q

What is the management of uncomplicated appendicitis?

A

appendicectomy

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49
Q

What is complicated appendicitis?

A

appendicitis + complications (perforation, appendix mass, abscess)

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50
Q

What is the management of complicated appendicitis?

A

fluids, IV abx, laparotomy to remove appendix

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51
Q

what age is Gastro-oesophageal reflux common and why?

A

infancy

inappropriate relaxation of the LOS due to functional immaturity

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52
Q

what are the risk factors for Gastro-oesophageal reflux

A

fluid diet
horizontal posture
short intra-abdominal length

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53
Q

How does Gastro-oesophageal reflux usually present?

A

recurrent regurgitation
distress after feeds
child is usually well and putting on weight

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54
Q

In who is severe gastro-oesophageal reflux common in?

A

cerebral palsy
preterm
following surgery for oesophageal atresia or diaphragmatic hernia

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55
Q

What are the complications of gastro-oesophageal reflux?

A

failure to thrive -severe vomiting
oesophagitis - haematemesis, discomfort on feeding, anaemia
pneumonia - due to recurrent aspiration

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56
Q

What are the ix for gastro-oesophageal reflux?

A

USUALLY CLINICAL
24h oesophageal pH monitoring to quantify degree of reflux
endoscopy w oesophageal biopsy

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57
Q

What is the management of gastro-oesophageal reflux?

A
  1. thickening agents to feeds
  2. position 30 degree head up
  3. avoid overfeeding
  4. alginate therapy
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58
Q

What treatment may be needed in severe gastro-oesophageal reflux?

A

PPI - omeprazole
H2 receptor antagonist - ranitidine
Domperidone to enhance gastric emptying

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59
Q

what is a differential of gastro oesophageal reflux?

A

cows milk protein intolerance if vomitign

60
Q

What is the treatment of gastro-oesophageal reflux that is either complicated or due to oesophageal strictures?

A

surgical

Nissen fundoplication

61
Q

What is a typical presentation of toddler diarrhoea?

A

stools of varying consistency
undigested veg in stools
well and thriving w no precipitating dietary factors

62
Q

What is the management of toddler diarrhoea?

A

Usually none - most grow out by 5yrs
Diet adequate in fat relieves sx (slows gut transit)
reduce fresh fruit juice, can exacerbate

63
Q

What should you consider in a child failing to thrive w chronic diarrhoea?

A

coeliac disease

cow’s milk protein intolerance

64
Q

What should you consider in a child w chronic diarrhoea following gastroenteritis?

A

post-gastroenteritis syndrome and associated temporary lactose intolerance

65
Q

what is the most common cause of chronic diarrhoea in the developed world?

A

cows milk protein intolerance

66
Q

What motility disorders cause increased stool in diarrhoea?

A

thyrotoxicosis
IBS
dumping syndrome

67
Q

What motility disorders cause decreased stool in diarrhoea?

A

pseudo-obstruction

intussusception

68
Q

What are inflammatory causes of diarrhoea? (bloody)

A

Infectious: shigella, salmonella, rotavirus, campylobacter, Crohn’s/UC, coeliac, haemolytic uraemia syndrome

69
Q

What are causes of watery stools in diarrhoea?

A

Cholera
c.diff
ecoli

70
Q

What is the most common cause of gastroenteritis?

A

rotavirus

71
Q

What are the features of gastroenteritis?

A

loose or water stools (sudden)
vomiting
contact w person w D&V
travel abroad?

72
Q

What is a major complication of gastroenteritis?

A

dehydration

73
Q

what is the treatment of gastroenteritis w no dehydration?

A 
prevent dehydration 
continue breast feeding
encourage fluids
oral rehydration therapy (dioralyte)
no fruit juice
74
Q

What is clinical dehydration defined as?

A

5-10% loss of body weight

75
Q

what is shock defined as in dehydration?

A

> 10% loss of body weight

76
Q

What are red flag sins of clinical dehydration

A 
unwell/deteriorating
altered responsiveness
sunken eyes
tachycardia
tachypnoea
reduced skin turgor
77
Q

What are the ix in dehydration?

A

usually none

stool culture?

78
Q

what is the rx of clinical dehydration

A

ORS
fluid deficit replacement (50ml/kg) + maintenance fluid
continue breastfeeding
NG tube if vomiting or inadequate fluid intake

79
Q

What is the rx of shock in dehydration?

A

IV therapy

rapid infusion of 0.9% NaCl solution

80
Q

Explain IV therapy for rehydration

A

replace fluid deficit + maintenance fluids
give 0.9% NaCl +/- 5% glucose
maybe K+ supplementation

81
Q

What is important to avoid when dehydrated?

A

fruit juices

carbonated drinks

82
Q

How is post-gastroenteritis syndrome confirmed:

A

presence of non-absorbed sugar in stools - +ve clinitest result

83
Q

What is post-gastroenteritis syndrome?

A

intro of normal diet making watery diarrhoea return

84
Q

What is the management of post-gastroenteritis syndrome?

A

ORS for 24hr

85
Q

What is the classical presentation of crohns?

A 
growth failure
delayed puberty
abdo pain
diarrhoea
 weight loss
general: fever, lethargy
86
Q

What are the extra-intestinal manifestations of crohns

A 
oral lesions
perianal skin tags
uveitis
arthralgia
erythema nodosum
87
Q

How is a diagnosis of crohns made?

A

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
Q

What is the pharmacological management of crohns?

A
  1. immunosuppressants: azathioprine, methotrexate
  2. Ant-TNF agents - infliximab, adalimumab
  3. Supplemental enteral nutrition for growth failure
89
Q

When is surgery necessary in crohns?

A

obstruction
fistulae
abscess formation
severe localised disease unresponsive to medical treatment

90
Q

What is the presentation of UC?

A

Rectal bleeding
Diarrhoea
Colicky pain

91
Q

What features are more common in crohns than UC?

A

weight loss and growth failure

92
Q

What are the extraintestinal manifestations of UC?

A

erythema nodosum

arthritis

93
Q

What is pancolitis?

A

UC spread throughout entire length of colon

94
Q

How is a diagnosis of UC made?

A 
endoscopy and biopsy 
there is:
mucosal inflammation
crypt damage
ulceration
95
Q

What is the management of uC?

A
  1. aminosalicylates - balsazide, mesalazine (induction and maintenance therapy)
  2. systemic steroids (azathioprine) for aggressive disease
96
Q

What is a complication of UC?

A

severe fulminating disease

97
Q

What is the treatment of the serious complication of UC?

A

IV fluids
steroids
Ciclosporin (if above 2 fail)

98
Q

What malignancy are adults w UC at risk of?

A

adenocarcinoma of the colon

99
Q

What is the rx of UC confined to the rectum and sigmoid colon?

A

topical steroids

100
Q

What is the difference between Crohn’s and UC regarding what part of the GI tract is affected?

A

Crohns - ANY part, oral and perianal disease

UC - only colon, starts in rectum, extends proximally

101
Q

What is the difference between Crohn’s and UC regarding involvement

A

Crohns - skip lesions

UC - continuous involvement

102
Q

What is the difference between Crohn’s and UC regarding the mucosa?

A

Crohns has deep ulcers and fissures, cobblestone

UC - red mucosa, bleeds easily, ulcers and pseudopolyps

103
Q

What is the difference between Crohn’s and UC regarding which parts of the GI wall are inflamed?

A

Crohns - transmural

UC - mucosal

104
Q

What is the difference between Crohn’s and UC regarding histology?

A

Crohns - granulomas

UC - no granulomata, goblet cell depletion, crypt abscesses

105
Q

What is Hirschsprung’s disease?

A

absence of the myenteric nerve plexus (Auerbach and Meissner) in the rectum which may extend along the colon

106
Q

How does Hirschsprung’s disease present?

A
  • no passage of meconium w/in 48h of birth and the abdomen distends
  • older children: constipation, abdominal distension
107
Q

What is Hirschsprung’s disease associated w?

A

Down’s syndrome

3x more common in males

108
Q

How does Hirschsprung’s disease present?

A
  • no passage of meconium w/in 48h of birth and the abdomen distends
  • older children: constipation, abdominal distension
109
Q

What is Hirschsprung’s disease associated w?

A

Down’s syndrome

3x more common in males

110
Q

What are features suggesting hyponatraemic dehydration

A 
jittery movements
increased muscle tone
hyperreflexia
convulsions
drowsiness or coma
111
Q

What children are at increased risk of dehydration?

A 
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
Q

What is posseting?

A

effortless regurgitation of milk

common

113
Q

What are the main causes of vomiting?

A 
posseting
between feeds
GOR
gastritis/gastroenteritis 
Overfeeding
pyloric stenosis
infections
adverse food reactions
114
Q

What causes bile-stained vomit?

A

intestinal obstruction

duodenal or volvulus

115
Q

What causes haematemesis?

A

oesophagitis
peptic ulcer
oral/nasal bleeding

116
Q

What are the causes of bloody stools?

A

intussusception

gastroenteritis - campylobacter or salmonella

117
Q

What are the causes of severe dehydration/shock

A

severe gastroenteritis
systemic infection
DKA

118
Q

What are causes of failure to thrive?

A

GOR

Coeliac

119
Q

What are causes of abode distension?

A

obstruction

120
Q

What is the cause of vomiting at the end of paroxysmal coughing?

A

whooping cough

121
Q

what are the different causes of intestinal obstruction?

A 
pyloric stenosis
atresia
intussusception
malrotation
volvulus
strangulated inguinal hernia
hirschsprungs
adhesions
foreign body
122
Q

When should diarrhoea be investigated in a child?

A

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
Q

What is Meckel’s diverticulum?

A

vestigial remnant of the Vitelline duct

124
Q

How does meckels diverticulum present

A 
Most asymptomatic
May present w:
−	Severe rectal bleeding
−	Intussusception
−	Volvulus 
−	Diverticulitis
125
Q

How is meckel’s diverticulum diagnosed?

A

Technetium scan

126
Q

What is the treatment of meckel’s diverticulum?

A

surgical resection

127
Q

What is the average frequency of stools in the 1st week of life?

A

4 a day

128
Q

What is the average frequency of stools at 1yr age?

A

2 a day

129
Q

What is average frequency of stool by 4yrs of age?

A

3 per day to 3 a week

130
Q

What are causes of constipation?

A 
Mostly idiopathic!
Dehydration 
Low-fibre diet
Meds e.g. opiates
anal fissure
potty training gone wrong 
hypothyroidism, hypercalcaemia
Hirschsprung 
LDs
131
Q

What are Ix for constipation?

A

examination - palpable abdo mass

DRE if pathological cause suspected

132
Q

what does failure to pass meconium in the first 24hrs of life indicate?

A

Hirschsprung disease

133
Q

What does failure to thrive and constipation indicate?

A

hypothyroidism
coeliac
hirschsprung

134
Q

What does perianal fistulae, abscesses or issues indicated with constipation?

A

perianal crohns

135
Q

why does constipation and diarrhoea occur at the same time?

A

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
Q

Give then management of constipation

A
  1. macrogol laxative - movicol
  2. stimulant laxative (Senna)
  3. +/- osmotic laxative - lactulose
  4. enema or manual evacuation
137
Q

When should constipation be suspected?

A

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
Q

when should faecal impaction be suspected?

A
  1. hx of severe sx of constiopation
  2. overflow soiling
  3. faecal mass palpable on abdominal examination
139
Q

What are behavioural interventions for constipation?

A

scheduled toileting
bowel habit diary
reward systems

140
Q

what are complications of idiopathic constipation?

A 
anal fissure
haemorrhoids
rectal prolapse
megarectum
faecal impaction and soiling
volvulus 
distress
141
Q

give red flags of constipation that indicate hirschsprungs

A

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
Q

Give a red flag of constipation that may indicate CF

A

Delay in passing meconium for more than 48h after birth

143
Q

what does ribbon stool pattern in constipation indicate?

A

anal sphincter stenosis

144
Q

give red flag sx of constipation that hint at neurological problems

A

Leg weakness/ motor delay - spinal cord abnormality

abnormalities in gluteal muscles

145
Q

Give amber flags of constipation

A 
faltered growth (systemic)
constipation triggered by intro of cows milk
poss child maltreatment

Paediatrics (56 decks)

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