GI Flashcards
1
Q
When might an abdominal XR be indicated on a child?
A
- Abdominal distension e.g. obstruction.
- Abdominal pain of unknown cause.
- Constipation.
2
Q
Give 3 gastrointestinal causes of abdominal pain.
A
- IBS.
- Constipation.
- Gastritis.
- Peptic ulcer.
- Malrotation.
- Appendicitis.
- IBD.
- Abdominal migraine.
3
Q
Give 3 gynaecological causes of abdominal pain.
A
- Dysmenorrhoea.
- PID.
- Ectopic pregnancy.
- Ovarian torsion.
4
Q
Give 3 hepatobiliary/pancreatic causes of abdominal pain.
A
- Hepatitis.
- Gall stones.
- Pancreatitis.
5
Q
Give 2 urinary causes of abdominal pain.
A
- UTI.
2. Pelvic ureteric junction obstruction.
6
Q
Give 5 signs of appendicitis.
A
- Anorexia.
- Pyrexia.
- Abdominal pain - initially central as the appendix is a mid gut structure but then localises to R side as the appendix irritates peritoneum.
- Vomiting.
- RIF rebound tenderness.
7
Q
Why is central trauma and bruising to the abdomen a concern?
A
Mid-line structures such as the pancreas, spleen, bowel and liver may be damaged.
8
Q
If you suspect trauma and abdominal organ damage what investigation might you do?
A
CT abdomen
9
Q
Give 5 differentials for abdominal pain + rectal bleeding.
A
- Anal fissures.
- Haemorrhoids.
- Polyps.
- Proplapse.
- Infective causes.
- Meckel diverticulum. If melaena, suspect gastritis or duodenal ulcer.
10
Q
What is Meckel diverticulum a remnant of?
A
omphalomesenteric duct
11
Q
Give 3 signs of Meckel diverticulum.
A
- Severe rectal bleeding.
- Intussusception.
- Volvulus.
12
Q
How would you treat Meckel diverticulum?
A
Surgical resection.
13
Q
Give 3 differentials for abdominal mass.
A
- Constipation.
- Appendicitis.
- Organomegaly.
- Nephroblastoma/Wilm’s tumour.
14
Q
Give 5 differentials for vomiting.
A
- GORD.
- Infection e.g. gastroenteritis.
- Food allergy/intolerance.
- Intestinal obstruction.
- Appendicitis.
- Coeliac disease.
- Over-feeding - common in bottle-fed infants.
- Necrotising enterocolitis.
- Malrotation - biliary vomit.
- DKA.
15
Q
Give 3 causes of intestinal obstruction that can cause vomiting.
A
- Pyloric stenosis.
- Duodenal atresia.
- Intussusception.
- Hirschsprung’s.
16
Q
What is pyloric stenosis?
A
A disease characterised by hypertrophy of the pyloric muscle causing gastric outlet obstruction.
17
Q
Give 3 signs of pyloric stenosis.
A
- ‘projectile’ vomiting, typically 30 minutes after a feed
- constipation and dehydration may also be present
- a palpable mass may be present in the upper abdomen
- hypochloraemic, hypokalaemic alkalosis due to persistent vomiting
18
Q
You suspect pyloric stenosis in a neonate. What investigations might you do?
A
- U+E.
- Blood gas.
- Dx: USS - hypertrophy of pyloric sphincter.
19
Q
You do a blood gas on a neonate with pyloric stenosis. What would it show?
A
Metabolic Alkalosis - low K+ and Cl-. The baby has vomited up all the HCl and the kidneys go into overdrive - increased K+ secretion.
20
Q
How would you manage a neonate with pyloric stenosis?
A
- IV fluids.
- Repeat gases to monitor alkalosis.
- NBM.
- Pyloromyotomy once stable.
21
Q
How might malrotation in a neonate present?
A
Obstruction with bilious vomiting.
Abdominal pain and tenderness.
22
Q
Any child presenting with dark green vomiting needs what urgent investigation?
A
An urgent upper GI contrast study to assess intestinal rotation.
23
Q
Give a potential consequence of malrotation.
A
SMA blood supply to the small intestine can be compromised -> infarction.
24
Q
What is duodenal atresia?
A
A congenital absence or complete closure of the duodenum. It causes intestinal obstruction in neonates.
25
You do an AXR on a neonate with duodenal atresia. What would you expect to see?
A double bubble sign.
26
What syndrome is associated with duodenal atresia?
20-40% have Down's syndrome.
27
What is intussusception?
Where proximal bowel telescopes into a distal segment -> obstruction, inflammation, bloody stools.
28
Give 2 signs of intussusception.
paroxysmal abdominal colic pain
during paroxysm the infant will characteristically draw their knees up and turn pale
vomiting
bloodstained stool - 'red-currant jelly' - is a late sign
sausage-shaped mass in the right upper quadrant
29
What investigations might you do on a child who you suspect has an intussusception?
USS - 'target sign'.
| AXR.
30
Describe the treatment for intussusception.
reduction by air insufflation under radiological control,
| if this fails, or the child has signs of peritonitis, surgery is performed
31
Give 5 causes of bilious vomiting in children.
1. Volvulus.
2. Hirschsprung's.
3. Necrotising enterocolitis.
4. Intussusception.
5. Bowel obstruction.
6. Strangulated hernia.
7. Adhesions.
32
What biochemical derangement might you see in a patient with pyloric stenosis?
Metabolic alkalosis.
33
What is the name of the surgery that can be used to treat pyloric stenosis?
Pyloromyotomy.
34
What area of the brain does high levels of unconjugated bilirubin affect?
The basal ganglia.
35
What can you see on X-ray of necrotising enterocoliris?
Dilated bowel loops (often asymmetrical in distribution)
Bowel wall oedema
Pneumatosis intestinalis (intramural gas)
Portal venous gas
Pneumoperitoneum resulting from perforation
Air both inside and outside of the bowel wall (Rigler sign)
Air outlining the falciform ligament (football sign)
36
What is the dx criteria for constipation?
<1y:
```
1. Stool pattern:
Fewer than 3 complete stools per week (type 3 or 4 on Bristol Stool Form Scale) (this does not apply to exclusively breastfed babies after 6 weeks
of age)
Hard large stool
'Rabbit droppings' (type 1)
```
2. Symptoms associated with defecation:
Distress on passing stool
Bleeding associated with hard stool
Straining
3. History
Previous episode(s) of constipation
Previous or current anal fissure
>1y
1. Stool pattern:
Fewer than 3 complete stools per week (type 3 or 4)
Overflow soiling (commonly very loose, very smelly, stool passed without sensation)
'Rabbit droppings' (type 1)
Large, infrequent stools that can block the toilet
2. Symptoms associated with defecation:
Poor appetite that improves with passage of large stool
Waxing and waning of abdominal pain with passage of stool
Evidence of retentive posturing: typical straight legged, tiptoed, back arching
posture
Straining
Anal pain
3. History
Previous episode(s) of constipation
Previous or current anal fissure
Painful bowel movements and bleeding associated with hard stools
37
List 10 causes of constipation.
```
idiopathic (most cases)
dehydration
low-fibre diet
medications: e.g. Opiates
anal fissure
over-enthusiastic potty training
hypothyroidism
Hirschsprung's disease
hypercalcaemia
learning disabilities
```
38
List 3 factors which suggest faecal impaction.
1. symptoms of severe constipation
2. overflow soiling
3. faecal mass palpable in abdomen
39
What is the mx of constipation?
1. polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen as the first-line treatment
2. add a stimulant laxative if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks
substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if Movicol Paediatric Plain is not tolerated
40
What is the school exclusion criteria for whooping cough?
2 days after commencing antibiotics (or 21 days from onset of symptoms if no antibiotics )
41
What is the school exclusion criteria for chicken pox?
Cases of chickenpox are generally infectious from 2 days before the rash appears to 5 days after the onset of rash.
Although the usual exclusion period is 5 days, all lesions should be crusted over before children return to nursery or school.
42
How is malrotation diagnosed?
Diagnosis is made by upper GI contrast study and USS
43
How is malrotation managed?
Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a Ladd's procedure is performed
44
Describe features of malrotation.
1. High caecum at the midline
2. Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia
3. May be complicated by the development of volvulus, an infant with volvulus may have bile stained vomiting
45
What is Hirschsprung's disease?
Absence of ganglion cells from myenteric and submucosal plexuses
46
How is Hirschsprung's diagnosed?
Full thickness rectal biopsy
47
List 2 features of Hirschsprung's.
1. Delayed passage of meconium
| 2. Abdominal distension
48
How is Hirschsprung's managed?
Rectal washouts initially, after that an anorectal pull through procedure
49
List 2 features of meconium ileus.
1. Delayed passage of meconium
2. Abdominal distension
The majority have cystic fibrosis
50
What is seen on X-ray of meconium ileus.
X-Rays will not show a fluid level as the meconium is viscid, PR contrast studies may dislodge meconium plugs and be therapeutic
51
What is the mx of meconium ileus?
Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs
52
List 2 features of biliary atresia.
Jaundice > 14 days
| Increased conjugated bilirubin
53
How is biliary atresia treated?
Urgent Kasai procedure.
54
What is the main risk factor of necrotising enterocolitis?
Prematurity
55
What are the features of necrotising enterocolitis?
Early features include abdominal distension and passage of bloody stools
56
What is the mx of necrotising enterocolitis?
1. Treatment is with total gut rest and TPN
| 2. Babies with perforations will require laparotomy
57
List 5 features of cow's milk protein intolerance (CMPI).
1. regurgitation and vomiting
2. diarrhoea
3. urticaria, atopic eczema
4. 'colic' symptoms: irritability, crying
5. wheeze, chronic cough
rarely angioedema and anaphylaxis may occur
58
How is CMPI/CMPA diagnosed?
skin prick/patch testing
| total IgE and specific IgE (RAST) for cow's milk protein
59
What is the mx of CMPI?
Management if formula-fed:
1. Mild-moderate - extensive hydrolysed formula (eHF) milk is the first-line replacement formula for infants
2. Severe - amino acid-based formula (AAF) in infants with severe CMPA or if no response to eHF
Management if breast-fed:
1. continue breastfeeding
2. eliminate cow's milk protein from maternal diet.
3. Consider prescribing calcium supplements for breastfeeding mothers whose babies have, or are suspected to have, CMPI, to prevent deficiency whilst they exclude dairy from their diet
4. use eHF milk when breastfeeding stops, until 12 months of age and at least for 6 months
60
Give 4 Ddx of diarrhoea in infants.
1. most common cause in the developed world is cows' milk intolerance
2. toddler diarrhoea
3. coeliac disease
4. post-gastroenteritis lactose intolerance
61
Describe gastroschisis.
A congenital defect in the anterior abdominal wall just lateral to the umbilical cord
62
Describe exomphalos.
Abdominal contents protrude through the anterior abdominal wall but are covered in an amniotic sac formed by amniotic membrane and peritoneum
