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GI and Liver Flashcards

1
Q

What age is soiling most common?

A

Age 5-10 years

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2
Q

What % of school children suffer from constipation?

A

5-30%

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3
Q

What general terms are used to describe constipation?

A

Infrequent defecation, painful dedication, or both

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4
Q

What is chronic constipation?

A

Two or more of the following in the preceding 8 weeks:

1) Fewer than 3 bowel movements / week
2) More than 1 episode of faecal incontinence / week
3) Either palpable stools in abdo, or large stools palpable rectally
4) Passing stools so large they block the toilet
5) Retentive posturing and withholding behaviours
6) Painful defecation

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5
Q

What is faecal incontinence? How can it broadly be split?

A

Passage of stool in inappropriate places:

1) Organic faecal incontinence = from organic disease

2) Functional = without organic disease, either:
- Constipation-associated faecal incontinence
- Non-retentive faecal incontinence (no constipation associated) = passage of stools in inappropriate places in children >4yrs with no evidence of constipation

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6
Q

What is faecal impaction?

A

Large faecal mass (abdo or rectal assessed by abdo, rectal or other methods of examination) unlikely to be passed on demand

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7
Q

What is pelvic floor dyssynergia?

A

Inability to relax pelvic floor when attempting to defecate

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8
Q

What is the pathophysiology of constipation?

A

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

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9
Q

What psychosocial factors may be associated with constipation in children?

A

1) Psychological problems
2) Major life events eg parental divorce, bullying, sexual abuse
3) Neurodevelopmental disorders
4) Autism
5) Issues toilet training

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10
Q

What features are important to ask about in a constipation hx?

A

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

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11
Q

In an infant aged <6 months, what causes straining and crying for 10 minutes before passage of stools?

A

Dyschezia = painful or difficult defecation which resolves spontaneously

Often mistaken for constipation

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12
Q

What is pain on defecation likely to lead to? Does this resolve?

A

Withholding

Toddlers and older children get better at withholding

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13
Q

What should examination of a child with constipation include? (3)

A

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

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14
Q

What are some organic causes of constipation? (9)

A

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

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15
Q

When do most of the organic causes of constipation present?

A

First few weeks of life

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16
Q

How should anorectal malformations be investigated?

A

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
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17
Q

How common is anal fissure? What is it associated with?

A

Common

Associated with painful defecation

Passage of blood and sentinel pile on anterior anus = characteristic

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18
Q

What may cause rectal prolapse? (4)

A

1) Chronic straining
2) Constipation
3) Disorders of sacral nerve innervation
4) Chronic diarrhoea

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19
Q

What is Hirschsprung’s disease?

A

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

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20
Q

How does Hirschsprung’s disease present in neonates? (3)

A

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

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21
Q

How does Hirschsprung’s disease present older infants and children?

A

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

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22
Q

What can develop in children with Hirschsprung’s disease?

A

Enterocolitis = at any age

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23
Q

How may enterocolitis present?

A

Abdo pain
Fever
Foul smelling and possibly bloody diarrhoea
Vomiting

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24
Q

What may happen in enterocolitis if not spotted early?

A

May progress to sepsis, transmural intestinal necrosis and perforation

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25
What is the mortality of enterocolitis?
30-35% Accounts for most of the mortality associated with Hirschsprung's disease
26
When does Hirschsprung's disease usually present?
Early - well inside first month
27
What investigations are done for Hirshsprung's disease?
Rectal biopsy = test of choice NOT anorectal manometry
28
What investigations are done for neurenteric problems?
Colonic motility = test of choice Colonic transit +/- rectal biopsy
29
What investigations are done for spinal cord problems?
MRI = investigation of choice Physical examination +/- anorectal manometry
30
What is anorectal manometry?
Measures pressures of anal sphincter muscles, sensation in the rectum and neural reflexes that are needed for normal bowel movements
31
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
32
What toxicity may cause constipation and what should be investigation should be performed?
Lead levels Toxicity screen
33
What investigations may be performed for cow's milk allergy?
Elimination diet Allergy testing
34
What investigations are done for functional / idiopathic constipation?
Hx and examination are most important and further tests are rarely necessary Further investigations are recommended occasionally in chronic constipation and always in non-retentive faecal incontinence, specifically: - Radiology (kidneys, ureter, bladder - Colonic transit
35
What is features are needed to confirm constipation is present in a child <1 yr? What about an older child?
At least 2 of the following: 1) <3 complete stools / week (unless exclusively BF when infrequent stools can be normal 2) Large hard stool or 'rabbit droppings' 3) Sx associate with defecation: distress on passing stool, bleeding with hard school or straining 4) Past hx of constipation 5) Prev or current anal fissure An older child may have the above, plus: 6) Overflow soiling = the child may be unaware of passing loose, smelly stools, which may be thick and sticky, or dry and flaky 7) Large stools big enough to block the toilet 8) Poor appetite that improve with the passage of a large stool 9) Retentive posturing eg tiptoes, straight legged with an arched back 10) Staining, painful bowel movements and/or anal pain
36
What features make a diagnosis of idiopathic constipation likely? (5)
1) Hx of meconium being passed within 48hrs of birth (in a full-term baby) 2) Constipation begins at least a few weeks after birth 3) Precipitating factors present eg weaning, poor fluid intake 4) Abdo is soft and not distended, normal appearance of anus (rectal examination not required) 5) General health, growth and development are normal with normal gait, tone, and power in lower limbs
37
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
38
What is the management of functional / idiopathic constipation?
1) Disimpaction 2) Maintenance therapy 3) Modification of behaviour - eg regular toileting / reward systems 4) Incontinence - Explain involuntary nature to parents / school nurse - Regular toileting
39
What does disimpaction involve in the management of functional / idiopathic constipation?
- Initially osmotic laxative eg polyethylene glycol (PEG) 3350 + electrolyte eg Movicol - May increase symptoms eg soiling at first - If not tolerated, substitute for stimulant laxative either on its own or with lactulose (osmotic laxative) or faecal softener (decussate) if stools are hard - 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 Rectal treatments eg enemas should be avoided but may be needed in extreme cases under specialist supervision
40
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
41
Why should prolonged use of stimulant laxatives be avoided?
Causes atonic colon and hypokalaemia
42
What are some complications failure to correct functional constipation in children?
1) Faecal impaction 2) Chronic constipation 3) Megacolon (may predispose to or result from constipation) 4) Rectal prolapse 5) Anal fissure 6) Faecal soiling 7) Psychological effects
43
What is encopresis?
Deliberate defecation in inappropriate places = seek child psychiatrist
44
What is infective gastroenteritis in children?
Sudden onset of diarrhoea +/- vomitting
45
How common is gastroenteritis in children?
Very common - many children have >1 episode / year
46
What are the most causative organisms of gastroenteritis?
Mostly viral ``` Rotavirus (56%) Campylobacter (28%) Salmonella (11%) Norovirus (3%) Shigella (15%) E coli 0157 (1%) ```
47
What are the most causative organisms of gastroenteritis? ADD A CARD
Mostly viral ``` Rotavirus (56%) Campylobacter (28%) Salmonella (11%) Norovirus (3%) Shigella (15%) E coli 0157 (1%) ``` Bacterial more common <2yr ADD IN
48
List some risk factors for gastroenteritis
Poor hygiene Lack of sanitation Compromised immune system Poor food hygiene eg poorly cooked / unrefrigerated
49
List some risk factors for gastroenteritis
Poor hygiene Lack of sanitation Compromised immune system Poor food hygiene eg poorly cooked / unrefridgerated
50
What features are important to ask about to find the source to gastroenteritis? (3)
1) Recent contact with someone with acute d&v 2) Source of infection eg contaminated water / food 3) Recent travel abroad
51
Treatment with antibiotics may cause gastroenteritis caused by which organism?
Clostridium difficile colitis
52
How may gastroenteritis present?
``` Watery diarrhoea (+/- mucus) Vomiting Abdo cramps Fever Dehydration URTI symptoms = rotavirus ```
53
Which organisms cause bloody diarrhoea?
1) Campylobacter spp (mainly Campylobacter jejuni) 2) E coli 0157 3) Ebola
54
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
55
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
56
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
57
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
58
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
59
When may a stool sample be required in gastroenteritis?
1) If septicaemia is suspected 2) There is blood and/or mucus in the stool 3) Child is immunocompromised 4) Child recently been abroad 5) Child not improved by day 6) Uncertainty about gastroenteritis diagnosis
60
What is the concern about gastroenteritis caused by E coli?
Haemolytic uraemia syndrome
61
What are notable diseases related to gastroenteritis?
Food poisoning | Dysentery
62
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
63
Why can lactose intolerance occur after a viral gastroenteritis?
Loss of lactase from gut Usually temporary
64
What is protective against gastroenteritis?
``` Breast feeding Rotavirus vaccine (given orally at 2 and 3 months of age) ```
65
What is gastro-oesophageal reflux?
Non-forceful regurgitation of milk and other gastric contents into the oesophagus
66
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
67
When does GOR become GORD?
GORD = persistent, more frequent reflux that gives rise to troublesome symptoms or complications
68
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)
69
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 (reaped) 7) Neurodisability
70
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
71
How is a diagnosis made of GOR?
Majority clinically
72
What is laryngopharygneal reflux (LRD) in children?
LRD = reflux into larynx, oropharnyx and/or nasopharynx
73
What is LRD associated with? (7)
1) FTT 2) Laryngomalacia 3) Recurrent respiratory papillomatosis 4) Chronic cough 5) Hoarseness 6) Oesphagitis 7) Aspiration
74
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
75
What does frequent, projectile vomiting in infants up to 2 months old suggest?
Pyloric stenosis
76
What does bile-stained (green or yellow/green) vomit suggest?
Intestinal obstruction
77
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
78
What does onset of regurgitation and/or vomiting after 6 months of age and persisting after 1yr suggest?
Cause other than reflux eg UTI
79
What does vomiting + blood in stools suggest?
Bacterial gastroenteritis, infant's cow's milk protein allergy or acute surgical condition
80
What does abdo distension, tenderness or palpable mass suggest?
Acute surgical condition | Obstruction
81
What does chronic diarrhoea suggest?
Cow's milk protein allergy
82
What does vomiting + bulging fontanelle suggest?
Raised ICP eg meningitis
83
What does vomiting + dysuria suggest?
UTI
84
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
85
Infants and children with a high risk of atopy + vomiting are more likely to have what?
Cow's milk protein allergy
86
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
87
What would a 24hr ambulatory oesophageal pH study show in GOR?
Frequent dips in pH <4
88
What is a barium meal used for when investigating in GOR?
To exclude underlying abnormalities in oesophagus, stomach and duodenum other than GORD
89
When is an upper GI contrast study required urgently?
Unexplained bile-stained vomitting or dysphagia
90
What is the lifestyle management of GOR?
- Reassurance it is normal and most grow out of it by 1yr | - Positioning when g
91
What is the lifestyle management of GOR?
- Reassurance it is normal and most grow out of it by 1yr - Positioning when feeding - Milk thickener - Small frequent meals - Avoid carbonated or acidic food
92
What medications may be offered in GOR?
Antacids H2 receptor antagonists PPIs (specialist advice)
93
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
94
What surgery may rarely be required in GOR? When may it be required? WHAT IS
Nissens funcoplication / lap fundoplication - upper part of stomach is wrapped around LES to strengthen and prevent reflux
95
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
96
What features may be apparent in a child with recurrent reflux persisting later in childhood? (4)
Chronic cough Wheeze Clubbing Recurrent pneumonias
97
What conditions are associated with GOR? (4)
Cerebral palsy Down's syndrome Developmental delay Sandifer's syndrome
98
Are you concerned about bilious vomit?
YES - INTESTINAL OBSTRUCTION UNTIL PROVEN OTHERWISE
99
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
100
What are some red flags in a vomiting hx? (3)
Bile stained vomiting Projectile vomiting Haematemesis
101
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
102
What does an 'olive mass' indicate?
Pyloric stenosis

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