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Year 4 PAEDS > GI and Liver 2 > Flashcards

GI and Liver 2 Flashcards

1
Q

List some common causes of recurrent abdominal pain

A 
Bowel:
Acute appendicitis
Intussusception
Mesenteric adenitis
HSP
Peptic ulceration
IBD
Intestinal obstruction
Constipation
Gastroenteritis

Renal:
UTI
Hydronephrosis
Renal calculus

Abnormal migraine
Lead poisoning

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2
Q

What is important to include in a physical examination of a child presenting with recurrent abdo pain?

A

Growth - height and weight measurements

General exam - pallor, jaundice and clubbing

Abdo examination - hepatomegaly, splenomegaly, enlarged kidneys or distended bladder

Anorectal examination - not routine but necessary if ?sexual abuse or constipation

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3
Q

What may ESR show when investigating recurrent abdo pain?

A

Elevated in IBD

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4
Q

What may amylase levels be when investigating recurrent abdo pain?

A

Raised in pancreatitis

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5
Q

What may be analysed in a stool sample when investigating recurrent abdo pain?

A

Ova and parasites (x3 samples) - GI parasites eg giardiasis

Occult blood - GI blood loss eg IBD or peptic ulcer

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6
Q

What may a pelvic and abdo USS show when investigating recurrent abdo pain?

A 
Urinary obstruction at all levels
Oragomegaly
Abscesses
IBD
Peptic ulcer
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7
Q

What may an X-ray show when investigating recurrent abdo pain?

A

Plain abdo:

  • Constipation
  • Renal calculi (if radiopaque)
  • Lead poisoning

Barium swallow and follow through:

  • Oesophagitis and reflux
  • Peptic ulcer
  • IBD
  • Congenital malformations of the gut
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8
Q

What may an endoscopy show when investigating recurrent abdo pain?

A

Peptic ulceration

Colitis

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9
Q

What does periodic periumbilical pain in which the child is well between episodes suggest?

A

Idiopathic recurrent abdo pain

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10
Q

What does epigastric pain relived by food and acids suggest?

A

Peptic ulcer

NB in children <6years, pain is often exacerbated by food (opposite to adult pattern)

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11
Q

What does retrosternal pain, associated with vomiting and FTT suggest?

A

GORD

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12
Q

What is the type of abdo pain in Crohn’s disease?

A

Colicky

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13
Q

What does colicky recurrent abdo pain with hard, infrequent stools suggest?

A

Constipation

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14
Q

What does back or loin pain combined with dysuria, frequency and enuresis suggest?

A

UTI

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15
Q

What does lower abdo pain with vaginal discharge suggest?

A

PID

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16
Q

What does anorexia, irritability, pica, hypochromic microcytic anaemia suggest?

A

Lead poisoning

Abdo pain is variable / vernalised

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17
Q

What does recurrent, potentially severe, abdo pain with n&v suggest?

A

Abnormal migraine

May have FH migraine

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18
Q

What is haematocolpos?

A

Medical condition in which the vagina fills with menstrual blood

Often caused by the combination of menstruation with an imperforate hymen

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19
Q

How does a child typically respond to pain caused by peritonism?

A

Child lies very still and movement causes severe pain

Reluctance to move spontaneously, rebound tenderness, guarding and rigidity

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20
Q

What conditions remote from the abdomen may cause abdo pain?

A

Tonsillitis
Mesenteric adenitis
Basal pneumonia causing pain referred to the abdo

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21
Q

What may a plain abdo x-ray show when investigating acute abdo pain?

A

Intussusception

Obstruction

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22
Q

What may an USS be useful in showing when investigating acute abdo pain?

A

Intussusception

Exclude renal pathology

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23
Q

What is a contrast enema used for when investigating acute abdo pain?

A

For diagnosis and treatment of intussusception

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24
Q

What does acute abdo pain with tachycardia, anorexia and peritoneum suggest?

A

Acute appendicitis

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25
Q

What does acute abdo pain with intermittent screaming, pallor and ‘redcurrant jelly’ stool suggest?

A

Intussusception

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26
Q

What does acute abdo pain with recent viral infection and no peritonism suggest?

A

Mesenteric adenitis

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27
Q

What does acute abdo pain with joint pain / swelling, blood in stool and pupura on extensor surfaces suggest?

A

HSP

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28
Q

What does acute abdo pain worse at night that is relived by food suggest (if >6yr)?

A

Peptic ulceration

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29
Q

What are some red flags of acute abdo pain in children? (5)

A 
Peritonitic
Rigid abdo
Guarding
Focal signs of shock
Bilous vomiting
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30
Q

What ages does acute appendicitis most commonly affect?

A

> 5yr

But can affect any age

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31
Q

How does acute appendicitis present?

A

In older children, presents classically:
- Pain initially in periumbilical area, moving after a few hours to RIF

In young children it is difficult to diagnose - mother says child is in pain, also:

  • anorexia
  • reluctance to move

+/- constipation
+/- vomiting
+/- low-grade fever

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32
Q

What must be included in an examination of a child with suspected acute appendicitis?

A

Abdo exam - guarding and rebound tenderness. Pain at McBurney’s point

PR exam - marked tenderness against anterior rectal wall due to peritonism

33
Q

What investigations should be performed for acute appendicitis?

A

FBC - leucocytosis / neutrophilia

U&Es

Urinalysis to exclude infection

CT / USS if diagnosis uncertain or appendix abscess suspected

Abdo x-ray not very helpful

34
Q

How is acute appendicitis managed?

A

Surgical appendectomy

35
Q

What is the prognosis of acute appendicitis?

A

May take a few weeks for recovery

If intraperitoneal adhesions occur as a result of peritonitis, later bowel obstruction

36
Q

What are the different possible positions of the appendix?

A

Retrocolic and retrocaecal = 75%

Subcaecal and pelvic = 20%

Reto-ileal and pre-ileal = 5%

37
Q

What is the pathophysiology of appendicitis?

A

Begins with acute obstruction of the lumen of the appendix, often with a faecolith. After 6-12 hours an inflammatory process involves the full thickness of the wall of the appendix. After 24-36 hours the appendix will become gangrenous and perforate

NB blockage can also be from FB, cancer, or a swelling in response to any infection in the body

38
Q

What is McBurney’s triad?

A

1) Pain in RIF
2) Fever
3) N&V

39
Q

What is coeliac disease?

A

Autoimmune hypersensitivity reaction to gliadin, a protein found in gluten

Gluten is found in wheat and rye

40
Q

What does coeliac disease have associations with?

A

T1DM
Arthritis
Downs syndrome
Turner syndrome

41
Q

What can increase the risk of coeliac disease?

A

Early introduction of cereals into the diet (before 4 months)

42
Q

When do children with coeliac disease usually present?

A

<2yrs

43
Q

How does coeliac disease usually present in children? (4)

A

1) FTT
2) Irritability
3) Anorexia
4) Vomiting and diarrhoea
5) Pale and foul stools

But some have few symptoms

Can present with delayed puberty

44
Q

What may examination of a child with coeliac disease reveal?

A

1) Abdo distension
2) Wasted buttocks
3) Irritability
4) Pallor

Occasionally:

5) Mouth sores
6) Smooth tongue
7) Excessive bruising
8) Clubbing
9) Peripheral oedema

Most constant feature = decrease in weight gain and linear growth

45
Q

What may investigations show in coeliac disease?

A

FBC:
- Anaemia (usually iron deficient but folate may be low)

Steatorrhoea may be present and faecal smear will demonstrate fat globules

Coeliac antibody screening in blood:
- IgA anti-tissue translglutaminase or anti-endomysial antibodies

Small bowel endoscopy

Definitive diagnosis made by jejunal biopsy

46
Q

What is the characteristic finding on a jejunal biopsy of coeliac disease?

A

Subtotal villous atrophy

Crypt hyerplasia

47
Q

What is the management of coeliac disease?

A

Gluten-free diet
- Quick resolution of diarrhoea, good mood and good growth

Rechallenge after 2 years of diet to allow full villi regeneration and repeat biopsy

48
Q

What is a coeliac crisis?

A

Life-threatening dehydration due to diarrhoea accompanying malabsorption

49
Q

What genetics are associated with coeliac disease?

A

HLA-DQ2 or DQ8

50
Q

What is a classic skin manifestation of coeliac disease?

A

Dermatitis herpeteformis

51
Q

What is dermatitis herpetiformis?

A

Chronic, polymorphic, pruritic skin disease

52
Q

What do almost all pt with dermatitis herpetiformis have?

A

Detectable villous atrophy or minor mucosal changes

53
Q

When does the suck reflex develop?

A

35 weeks

Prom babies must be fed through NG tube

54
Q

What is a hydrocele?

A

Accumulation of fluid in the tunica vaginalis

Do not fluctuate in size (unless they communicate with the peritoneal cavity)

55
Q

What is the management of hydrocele?

A

Most resolve by age 1

Occasionally large ones persist and require surgical treatment

Rarely, in older boys can indicate malignancy

56
Q

What is an inguinal hernia?

A

Protrusion of abdo contents through the internal inguinal ring

Hernia contains a portion of peritoneal sac and may contain viscera, usually small bowel and omentum

57
Q

What are the two types of inguinal hernia?

A

Indirect

Direct

58
Q

What is an indirect inguinal hernia?

A

A protrusion through the internal inguinal ring passes along the inguinal canal through the abdo wall, running laterally to the inferior epigastric vessels

80% of inguinal hernias and most common in children

59
Q

What is an indirect inguinal hernia associated with?

A

Failure of the inguinal canal to close properly after passage of the testis in utero or during the neonatal period

60
Q

What is a direct inguinal hernia?

A

Hernia protrudes directly through a weakness in the posterior wall of the inguinal canal, running medially to the inferior epigastric vessels

More common in elderly and rare in children

61
Q

Are inguinal hernias more common in boys or girls? R or L?

A

Much more common in boys = persistent patency of processus vaginalis which normally closes at birth

More common on R side due to later descent of right testis

Particularly more common in preterm babies

62
Q

How may an inguinal hernia present?

A

Swelling in the groin which may extend down into the scrotum

Most obvious when intra-abdo pressure is raised eg crying, straining or coughing, often disappears when relaxed and lying down

Hernia is not painful unless incarcerated, when signs of intestinal obstruction may also be present

No transillumination

63
Q

What is diagnostic of an inguinal hernia?

A

Clinical observation of an inguinal or inguinoscrotal mass that reduces spontaneously or on manipulation

64
Q

How is an inguinal hernia managed?

A

Elective surgical herniotomy surgical procedure

  • Hernial sack is resected and defect repaired
  • Infants should be repaired within a few weeks as high risk of incarceration, but this lessens after age 1yr

If incarcerated and irreducible = emergency
- Advise parents of what to look for

65
Q

What % of inguinal hernias are bilateral?

A

15%

66
Q

What are some complications of inguinal hernias?

A

Incarceration leads to intestinal obstruction

30% risk of testicular infarction due to pressure on the gonadal vessels

67
Q

Ddx of inguinal hernia

A

Hydrocele - exclude with transillumination
Groin LN
Undescended testis

68
Q

What is intussusception? What is the pathophysiology?

A

Invagination / telescoping of one part of the bowel into another

The mesentery of this intussuscepted bowel becomes compressed. The bowel wall distends and obstructs the lumen. Peristalsis is disrupted leading to colicky abdo pain and vomiting. Lymphatic and venous obstruction occurs causing ischaemia

Can lead to a gangrenous bowel and possible perforation

69
Q

What is the most common part of the bowel to telescope into another part?

A

Usually ileum into the caecum (75%)

70
Q

What age group does intussusception usually affect?

A

3-24 months

Only 10% occur in those >3yr

71
Q

What may cause intussusception?

A

Most commonly follows a viral infection (adenovirus or rotavirus) in which enlarged lymphatic tissue in bowel walls (Peyer’s patch) form the leading edge of the intusussception (less flexible to peristalsis)

Rarely due to a pathological lesion such as polyp or lymphoma or as a complication of HSP (more common in older children)

72
Q

How may a child with intussusception present?

A

Episodic screaming and pallor and between episodes may appear well

Bile stained vomiting

+/- shock or dehydration

Passage of blood and mucus in stool = ‘redcurrant jelly’ stool

  • Present in 75%
  • But late sign
73
Q

What investigations are carried out for intussusception and what may they show?

A

Abdo radiograph:

  • Rounded edge of the intussusception against the gas-filled lumen of the distal bowel
  • With signs of proximal bowel obstruction

USS can confirm the presence of bowel within bowel = “doughnut sign”

74
Q

How can an intussusception be reduced?

A

By air or barium enema

Diagnostic and curative - pressure when the contrast is inserted can be gradually increased to force back the intussuscepting bowel which can be seen on fluoroscopy

Care not to apply to high a pressure which may lead to bowel perforation

Should only be performed is hx is <24hrs and no evidence of peritonism or severe dehydration

75
Q

When may a laparotomy be required in an intussusception?

A

If an air or barium enema fails to reduce it, or if there is evidence of peritonism

Surgical reduction then performed

76
Q

What may an abdo exam show reveal in intussusception?

A

Sausage shaped mass in the right side of the abdomen

77
Q

What should be considered if a child experiences repeated intussusception?

A

A polyp

78
Q

What is the prognosis of intussusception?

A

Good with prompt diagnosis

Risk of death if diagnosis missed

1% mortality with treatment

Post reduction recurrence 5-15%

Year 4 PAEDS (23 decks)

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