GI and Liver Flashcards
Define constipation
Constipation = the infrequent passage of dry, hardened faeces often accompanied by straining of pain (becomes chronic if > 8 weeks)
What is pelvic floor dyssynergia?
Inability to relax pelvic floor when attempting to defecate
What is the pathophysiology of constipation?
Begins as constipation leading to faecal retention. This leads to a vicious cycle as hard stools inhibit defecation and increases constipation. The rectum becomes distended with faecal impaction
In extreme cases, only liquid matter can escape = overflow diarrhoea
What psychosocial factors may be associated with constipation in children?
1) Psychological problems
2) Major life events eg parental divorce, bullying, sexual abuse
3) Neurodevelopmental disorders
4) Autism
5) Issues toilet training
What features are important to ask about in a constipation hx?
1) Frequency of defecation
2) Consistency of stools
- Can include Bristol Stool Chart
3) Episodes of faecal incontinence
4) Pain on defecation
5) Whether stools block toilet
6) Any associated behaviour
In an infant aged <6 months, what causes straining and crying for 10 minutes before passage of stools?
Dyschezia = painful or difficult defecation which resolves spontaneously
Often mistaken for constipation
What is pain on defecation likely to lead to? Does this resolve?
Withholding
Toddlers and older children get better at withholding
What should examination of a child with constipation include? (3)
1) Palpation of the abdo for faecal mass
2) Inspection for anal stenosis or anal ectopia
3) Checking for sacral abnormalities
NB rectal examination is not routinely required nor is routine radiology recommended
What are some organic causes of constipation? (9)
1) Anorectal malformation
2) Anal fissure
3) Rectal prolapse
4) Hirschsprung’s disease
5) Neurenteric problems
6) Spinal cord problems
7) Pelvic floor dyssynergia
8) Metabolic or systemic disorders
9) Toxic
10) Cow’s milk allergy
When do most of the organic causes of constipation present?
First few weeks of life
How should anorectal malformations be investigated?
Physical examination - inspecting the perineum in any baby with constipation
Checking if the anus is in the correct position relative to the vulva or scrotum
Digital exam (with little finger) occasionally - assess volume and hardness of rectal stool
What is classic for an anal fissure?
Passage of blood and sentinel pile on anterior anus = characteristic
What may cause rectal prolapse? (4)
1) Chronic straining
2) Constipation
3) Disorders of sacral nerve innervation
4) Chronic diarrhoea
What is Hirschsprung’s disease?
Absence of parasympathetic ganglion cells in the myenteric and submucosal plexus of the rectum, possibly extending to the colon
Leads to an aganglionic segment which is unable to relax = functional colonic obstruction
How does Hirschsprung’s disease present in neonates? (3)
1) Abdo distention
2) Failure to pass meconium within first 48hrs of life
3) Repeated vomiting
NB delayed passage of meconium is very important - nearly half of all infants with Hirschsprung’s disease do not pass meconium within 36hrs and nearly half of all infants with delayed first passage of meconium have Hirschsprung’s disease
How does Hirschsprung’s disease present older infants and children?
Can present with chronic constipation that is resistant to usual treatments and a daily enema may be required
Rarely soiling and overflow incontinence which is in contrast to children with functional constipation
Causes early satiety, abdo discomfort, distention and poor nutrition and eightgian
What can develop in children with Hirschsprung’s disease?
Enterocolitis = at any age
How may enterocolitis present?
Abdo pain
Fever
Foul smelling and possibly bloody diarrhoea
Vomiting
What may happen in enterocolitis if not spotted early?
May progress to sepsis, transmural intestinal necrosis and perforation
What is the mortality of enterocolitis?
30-35%
Accounts for most of the mortality associated with Hirschsprung’s disease
What investigations are done for Hirshsprung’s disease?
Rectal biopsy = test of choice
NOT anorectal manometry
What investigations are done for neurenteric problems?
Colonic motility = test of choice
Colonic transit
+/- rectal biopsy
What is anorectal manometry?
Measures pressures of anal sphincter muscles, sensation in the rectum and neural reflexes that are needed for normal bowel movements
What metabolic / systemic disorders may cause constipation and what investigations are done for them?
Hypothyroidism
- TFTs
Coeliac disease
- Total IgA and IgA tTG (tissue transglutaminase)
- Consider IgG EMA (endomysial antibodies), IgG GDP (gliadin peptides) or IgG tTG if IgA is deficient
Hypocalcaemia
- Calcium test
CF
- Sweat test
What toxicity may cause constipation and what should be investigation should be performed?
Lead levels
Toxicity screen
What investigations may be performed for cow’s milk allergy?
Elimination diet
Allergy testing
What are some red flags for constipation in children?
1) Symptoms commence from birth or in first few weeks
2) Failure or delay (>first 48hrs at term) in passing meconium
3) Ribbon stools
4) Leg weakness or locomotor delay
5) Abdo distension with vomiting
6) Abnormal examination findings:
- Abnormal appearance of anus
- Gross abdo distension
- Abnormal gluteal muscles, scoliosis, sacral agenesis etc
- Limb deformity including talipes
- Abnormal reflexes
What is the management of functional / idiopathic constipation?
1) Disimpaction dose of movicol
2) Maintenance therapy dose of movicol
3) Modification of behaviour
- eg regular toileting / reward systems
4) Incontinence
- Explain involuntary nature to parents / school nurse
- Regular toileting
What does disimpaction involve in the management of functional / idiopathic constipation?
Osmotic laxative eg polyethylene glycol (PEG) 3350 + electrolyte eg Movicol
(May increase symptoms eg soiling at first)
If not effective after 2 weeks:
Add stimulant laxative eg sodium picosulfate or Senna if >1 month
OR Decussate (softener and weak stimulant laxative) from 6mnths
OR bisacodyl suppositories from 2yrs
AVOID enemas (specialist)
What does maintenance therapy involve in the management of functional / idiopathic constipation?
- Dietary advice
- Stool charts
- Regular laxatives over months / years (preferably osmotic PEG 3350 or lactulose) titrated to maintain soft formed stool
- Avoid stopping and starting treatment causing intermittent impaction
- Avoid prolonged use of stimulant laxatives, only use intermittently to avoid impaction
Why should prolonged use of stimulant laxatives be avoided?
Causes atonic colon and hypokalaemia
What is encopresis?
Deliberate defecation in inappropriate places = seek child psychiatrist
What are the most causative organisms of gastroenteritis?
Mostly viral
Rotavirus (56%) Campylobacter (28%) Salmonella (11%) Norovirus (3%) Shigella (15%) E coli 0157 (1%)
Treatment with antibiotics may cause gastroenteritis caused by which organism?
Clostridium difficile colitis
How may gastroenteritis present?
Watery diarrhoea (+/- mucus) Vomiting Abdo cramps Fever Dehydration URTI symptoms = rotavirus
Which organisms cause bloody diarrhoea?
1) Campylobacter spp (mainly Campylobacter jejuni)
2) E coli 0157
3) Ebola
List some red flags in a child presenting with gastroenteritis
1) Appears to be unwell or deteriorating
2) Altered responsiveness eg irritable / lethargic
3) Sunken eyes
4) Tachycardia
5) Tachypnoea
6) Reduced skin turgor
What may severe dehydration from gastroenteritis lead to? How may this present?
Shock
1) Decreased level of consciousness
2) Pale / mottled skin
3) Cold extremities
4) Tachycardia
5) Tachypnoea
6) Weak peripheral pulses
7) Prolonged CRT
8) Hypotension
List some differentials for d&v
1) Other sites of infection eg UTI, OM, meningitis, pneumonia
2) Toddler’s diarrhoea
3) Constipation with overflow
4) Acute appendicitis (older children)
5) Mesenteric adenitis
6) Malrotation of the gut
7) Intussusception = ‘redcurrant jelly’ stool
- May be reported as bloody diarrhoea
8) Coeliac disease
9) Pyloric stenosis = projectile vomiting
10) Babies may get regurge or possetting
11) GORD
12) DKA
13) Addison’s disease
What investigations may be performed for gastroenteritis? (3)
1) Stool sample
2) Blood tests - FBC, renal function, U&Es
3) Blood culture if giving abx
NB E coli - need specialist
What is the concern about gastroenteritis caused by E coli?
Haemolytic uraemia syndrome
What are notable diseases related to gastroenteritis?
Food poisoning
Dysentery
What is the management of gastroenteritis?
Rest and fluids
ORS if increased risk of dehydration
Abx if septicaemia or <6 months with salmonella or immunocompromised
Do not return to school until at least 28hrs of last episode
Why can lactose intolerance occur after a viral gastroenteritis?
Loss of lactase from gut
Usually temporary
What is protective against gastroenteritis?
Breast feeding Rotavirus vaccine (given orally at 2 and 3 months of age)
What is gastro-oesophageal reflux?
Non-forceful regurgitation of milk and other gastric contents into the oesophagus
What is possetting? Is it concerning?
= Asymptomatic effortless regurgitation of a small quantity of milk after a feed
Normal in young infants and doesn’t need any investigations / treatment
When does GOR become GORD?
GORD = persistent, more frequent reflux that gives rise to troublesome symptoms or complications
How common is GOR in infancy?
More significant GOR (more than possetting) common approx 40% infants before 8 weeks old
Usually becomes less frequent with time (resolves in 90% before 1 yr)
What are some risk factors for GOR in children? (7)
1) Premature birth
2) FH
3) Obesity
4) Hiatus hernia
5) Hx congenital diaphragmatic hernia (repaired)
6) Hx congenital oesophageal atresia (repaired)
7) Neurodisability
How may GOR present in children?
1) Heartburn
2) Retrosternal pain
3) Epigastric pain
4) Recurrent regurgitation or vomiting
5) Witnessed episode of choking / apparent life-threatening event
6) Resp problems:
- Cough
- Apnoea
- Recurrent wheeze
- Aspiration pneumonia
7) Feeding and behavioural problems
8) FTT
What is laryngopharygneal reflux (LRD) in children?
LRD = reflux into larynx, oropharnyx and/or nasopharynx
What is LRD associated with? (7)
1) FTT
2) Laryngomalacia
3) Recurrent respiratory papillomatosis
4) Chronic cough
5) Hoarseness
6) Oesphagitis
7) Aspiration
When is LRD suspected? How is it confirmed?
Diagnosis based on high index of suspicion if there are no symptoms specially indicating GOR
Confirmed using endoscopy, pH probes and radiography
What does frequent, projectile vomiting in infants up to 2 months old suggest?
Pyloric stenosis
What does bile-stained (green or yellow/green) vomit suggest?
Intestinal obstruction
What does haematemesis suggest? What is important to ask about?
Potentially serious bleed from oesophagus, stomach or upper gut
Ask about swallowed blood eg following nosebleed or ingesting blood from cracked nipple in those BF
What does onset of regurgitation and/or vomiting after 6 months of age and persisting after 1yr suggest?
Cause other than reflux eg UTI
What does vomiting + blood in stools suggest?
Bacterial gastroenteritis, infant’s cow’s milk protein allergy or acute surgical condition
What does abdo distension, tenderness or palpable mass suggest?
Acute surgical condition
Obstruction
What does chronic diarrhoea in an infant suggest?
Cow’s milk protein allergy
What does vomiting + bulging fontanelle suggest?
Raised ICP eg meningitis
What does vomiting + dysuria suggest?
UTI
What does a rapidly increasing head circumference (>1cm/week) or persistent morning headache and vomiting worse in the morning suggest?
Raised ICP eg due to hydrocephalus or a brain tumour
Infants and children with a high risk of atopy + vomiting are more likely to have what?
Cow’s milk protein allergy
GOR does not usually need investigating. What investigations are performed in more serious cases of GOR?
1) FBC
2) 24hr ambulatory oesophageal pH study
3) Barium meal
4) Endoscopy
- If oeophagitis suspected
5) Mamometry
What would a 24hr ambulatory oesophageal pH study show in GOR?
Frequent dips in pH <4
What is a barium meal used for when investigating in GOR?
To exclude underlying abnormalities in oesophagus, stomach and duodenum other than GORD
When is an upper GI contrast study required urgently?
Unexplained bile-stained vomitting or dysphagia
What is the lifestyle management of GOR?
- Reassurance it is normal and most grow out of it by 1yr
- Positioning when feeding
- Milk thickener (if bottle fed)
- Small frequent meals
- Avoid carbonated or acidic food
What medications may be offered in GOR for those breastfeeding?
2 week trial of Gaviscon
If not working = try 4 weeks of PPI or H2 receptor antagonist (eg Ranitidine)
(specialist advice)
When should surgery be considered in children with GORD?
Required if severe, intractable GORD where management proves impractical eg long term, continuous, thickened enteral feeding
What surgery may rarely be required in GOR? What is it?
Nissens fundoplication / lap fundoplication
- upper part of stomach is wrapped around LES to strengthen and prevent reflux
What are some complications of GOR? (4)
1) Reflux oesophagitis
2) Recurrent aspiration pneumonia
3) Freq OM eg >3 in 6 months
4) Dental erosion in child with neruodisability esp CP
What features may be apparent in a child with recurrent reflux persisting later in childhood? (4)
Chronic cough
Wheeze
Clubbing
Recurrent pneumonias
What conditions are associated with GOR? (4)
Cerebral palsy
Down’s syndrome
Developmental delay
Sandifer’s syndrome
Are you concerned about bilious vomit?
YES - INTESTINAL OBSTRUCTION UNTIL PROVEN OTHERWISE
What is important to ask about in a vomiting hx
Vomiting:
- Bilious / non-bilious
- Colour
- Consistency
- Volume
- Nature
Growth/weight loss
Eating and drinking
Bowel habit
What are some red flags in a vomiting hx? (3)
Bile stained vomiting
Projectile vomiting
Haematemesis
What is important to assess when examining a child presenting with vomiting?
Well or not well child? Observations Fluid status: - Dehydration - Fontanelle - Eyes - Mucus membranes - CRT - Weight
Abdo exam:
- Inspection
- ‘Olive mass’
- Bowel sounds
- Groin
- Mouth
- Anus
ENT exam
- Infections
Head circumference
- ICP
End pieces:
- SHRUG
- Growth chart
- Glucose
- AXR/USS if indicated
What does an ‘olive mass’ indicate?
Pyloric stenosis
