GI Flashcards
What are the differential diagnoses for vomiting?
Gastroesophageal reflux
Overfeeding
Pyloric stenosis
Cow’s milk allergy
What are the symptoms of pyloric stenosis?
Vomiting - non-bilious, large volume, not keeping down feeds
Irritable and crying
Not gaining weight adequately
On examination - looks slightly dehydrated
Visible gastric peristalsis
What investigations would be done if pyloric stenosis was suspected?
Test feed
Ultrasound - see stenosed pyloric sphincter
Blood gases - high pH (metabolic alkalosis), low Cl and K
How is pyloric stenosis managed?
Fluid resuscitation
Refer to surgeons - ramstedts pyloromyotomy
What is bilious vomiting?
Green vomit
ALARM BELLS
What are the causes of bilious vomiting?
Intestinal obstruction until proven otherwise Intestinal atresia - only in new borns Malrotation Ileus Crohn's disease with strictures
What investigations would be done if bilious vomiting was suspected?
Abdominal x-ray
Consider contrast meal
Surgical opinion
How is bilious vomiting treated?
Nil by mouth
IV fluids
Surgical opinion
What are the causes of effortless vomiting?
GORD - LOS problem
What are the symptoms of effortless vomiting?
Vomiting Haematemesis Feeding problems Failure to thrive Apnoea Cough Wheeze Chest infections
How is effortless vomiting investigated?
History and examination usually enough Radiological - video fluoroscopy, barium swallow pH study Oesophageal impedance monitoring Endoscopy if severe
How is effortless vomiting treated?
Feeding advice - thickeners, feeding position, behavioural problem
Nutritional support - calorie supplements, try dairy free milk, NG tube, gastrostomy
Medical - feed thickener (gaviscon), pro kinetic drugs, acid suppressing drugs (PPIs)
Surgery
What is the definition of chronic diarrhoea?
4 or more stools per day
Acute diarrhoea <1 week
Persistent diarrhoea - 2-4 weeks
Chronic diarrhoea > 4 weeks
What are the causes of chronic diarrhoea?
Motility disturbance - toddler diarrhoea, IBS
Active secretion (secretory) - acute infective diarrhoea (cholera), IBD
Malabsorption of nutrients (osmotic) - food allergy, coeliac disease, CF
What are the types of chronic diarrhoea?
Osmotic
Secretory
Motility
Inflammatory
Osmotic diarrhoea
Movement of water into the bowel to equilibrate osmotic gradient
Usually a feature of malabsorption
Clinical remission with removal of causative agent
Stool - small volumes, stops when fasting
Secretory diarrhoea
Associated with toxin production - vibrio cholera, enterotoxigenic Escherichia coli
Intestinal fluid secretion is driven by active Cl- secretion (and therefore water) via CFTR
Stool - large volume, diarrhoea continues with fasting
Inflammatory diarrhoea
Malabsorption due to intestinal change
Secretory effect of cytokines
Accelerated transit time in response to inflammation
Protein exudate across inflamed epithelium
Where is fat malabsorption seen?
Pancreatic disease - diarrhoea due to lack of lipase and resultant steoatorrhea
Hepatobiliary disease - chronic liver disease, cholsetasis
Coeliac disease
Sensitivity to gluten
Autoimmune condition - antibodies form against gluten, complexes form when gluten that attack the small bowel
Coeliac disease - genetic susceptibility
HLA DQ2 and DQ8
What are the symptoms of coeliac disease?
Abdominal bloating Diarrhoea Failure to thrive Short stature Constipation - maybe Tiredness Dermatitis herpetiformit
How is coeliac disease investigated?
Serological screens - anti-tissue transglutaminase, anti-endomysial, IgA testing
Duodenal biopsy - don’t need
Genetic testing
How is coeliac disease treated?
Gluten-free diet for life
What are the symptoms of constipation?
Poor appetite Irritability Lack of energy Abdominal pain or distension Withholding or straining Can have diarrhoea
Why do children become constipated?
Social – poor diet (insufficient fluids, excessive milk), potty training/school toilet
Physical – intercurrent illness, medication
Family history
Psychological – secondary
Organic
What is the cycle of constipation?
Pain or anal fissure
Withholding of stool – the longer the stool stays in the colon the drier it gets so the harder it will be to pass
Constipation
Large hard stool
How is constipation treated?
Explain treatments to parents
Dietary - increase fruit and fibre, decrease milk
Psychological - make going to the toilet pleasant, reward good behaviour
Movicol - isotonic laxative
Lactulose - osmotic laxative
How is impactation treated?
Empty impacted rectum
Empty colon
Maintain regular stool passage
Slow weaning off treatment
What are the symptoms of Crohn’s disease?
Weight loss Growth failure Abdominal pain Diarrhoea Rectal bleeding Arthritis Mass
How is Crohn’s disease treated?
Induce remission – nutritional therapy, steroids
Maintain remission – thiopurines
Step-up therapy – anti-TNF
Surgery – only for complications, not curative
What are the symptoms of ulcerative colitis?
Diarrhoea
Rectal bleeding
Abdominal pain
Less systemic symptoms
How is ulcerative colitis treated?
Induce remission – 5-ASA, steroids
Maintain remission – 5-ASA, thiopurines
Step-up therapy – anti-TNF
Surgery – for failure to respond to medical therapy, curative
How is IBD investigated?
Stool calprotectin
FBC & ESR – anaemia, thrombocytosis, raised ESR
Biochemistry – raised CRP, low albumin
Microbiology – no stool pathogens
Definitive - MRI, barium meal, endoscopy (any kind)
If an infant had a cow’s milk allergy, what milk would you recommend?
Nutramigen - extensively hydrolysed protein feeds
