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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
Q

What is the mortality of enterocolitis?

A

30-35%

Accounts for most of the mortality associated with Hirschsprung’s disease

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26
Q

When does Hirschsprung’s disease usually present?

A

Early - well inside first month

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27
Q

What investigations are done for Hirshsprung’s disease?

A

Rectal biopsy = test of choice

NOT anorectal manometry

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28
Q

What investigations are done for neurenteric problems?

A

Colonic motility = test of choice

Colonic transit

+/- rectal biopsy

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29
Q

What investigations are done for spinal cord problems?

A

MRI = investigation of choice

Physical examination

+/- anorectal manometry

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30
Q

What is anorectal manometry?

A

Measures pressures of anal sphincter muscles, sensation in the rectum and neural reflexes that are needed for normal bowel movements

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31
Q

What metabolic / systemic disorders may cause constipation and what investigations are done for them?

A

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

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32
Q

What toxicity may cause constipation and what should be investigation should be performed?

A

Lead levels

Toxicity screen

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33
Q

What investigations may be performed for cow’s milk allergy?

A

Elimination diet

Allergy testing

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34
Q

What investigations are done for functional / idiopathic constipation?

A

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
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35
Q

What is features are needed to confirm constipation is present in a child <1 yr?

What about an older child?

A

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

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36
Q

What features make a diagnosis of idiopathic constipation likely? (5)

A

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

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37
Q

What are some red flags for constipation in children?

A

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

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38
Q

What is the management of functional / idiopathic constipation?

A

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

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39
Q

What does disimpaction involve in the management of functional / idiopathic constipation?

A
  • 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

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40
Q

What does maintenance therapy involve in the management of functional / idiopathic constipation?

A
  • 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
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41
Q

Why should prolonged use of stimulant laxatives be avoided?

A

Causes atonic colon and hypokalaemia

42
Q

What are some complications failure to correct functional constipation in children?

A

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
Q

What is encopresis?

A

Deliberate defecation in inappropriate places = seek child psychiatrist

44
Q

What is infective gastroenteritis in children?

A

Sudden onset of diarrhoea +/- vomitting

45
Q

How common is gastroenteritis in children?

A

Very common - many children have >1 episode / year

46
Q

What are the most causative organisms of gastroenteritis?

A

Mostly viral

Rotavirus (56%)
Campylobacter (28%)
Salmonella (11%)
Norovirus (3%)
Shigella (15%)
E coli 0157 (1%)
47
Q

What are the most causative organisms of gastroenteritis?

ADD A CARD

A

Mostly viral

Rotavirus (56%)
Campylobacter (28%)
Salmonella (11%)
Norovirus (3%)
Shigella (15%)
E coli 0157 (1%)

Bacterial more common <2yr ADD IN

48
Q

List some risk factors for gastroenteritis

A

Poor hygiene
Lack of sanitation
Compromised immune system
Poor food hygiene eg poorly cooked / unrefrigerated

49
Q

List some risk factors for gastroenteritis

A

Poor hygiene
Lack of sanitation
Compromised immune system
Poor food hygiene eg poorly cooked / unrefridgerated

50
Q

What features are important to ask about to find the source to gastroenteritis? (3)

A

1) Recent contact with someone with acute d&v
2) Source of infection eg contaminated water / food
3) Recent travel abroad

51
Q

Treatment with antibiotics may cause gastroenteritis caused by which organism?

A

Clostridium difficile colitis

52
Q

How may gastroenteritis present?

A 
Watery diarrhoea (+/- mucus)
Vomiting
Abdo cramps
Fever
Dehydration
URTI symptoms = rotavirus
53
Q

Which organisms cause bloody diarrhoea?

A

1) Campylobacter spp (mainly Campylobacter jejuni)
2) E coli 0157
3) Ebola

54
Q

List some red flags in a child presenting with gastroenteritis

A

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
Q

What may severe dehydration from gastroenteritis lead to? How may this present?

A

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
Q

List some differentials for d&v

A

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
Q

List some differentials for d&v

A

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
Q

What investigations may be performed for gastroenteritis? (3)

A

1) Stool sample
2) Blood tests - FBC, renal function, U&Es
3) Blood culture if giving abx

NB E coli - need specialist

59
Q

When may a stool sample be required in gastroenteritis?

A

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
Q

What is the concern about gastroenteritis caused by E coli?

A

Haemolytic uraemia syndrome

61
Q

What are notable diseases related to gastroenteritis?

A

Food poisoning

Dysentery

62
Q

What is the management of gastroenteritis?

A

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
Q

Why can lactose intolerance occur after a viral gastroenteritis?

A

Loss of lactase from gut

Usually temporary

64
Q

What is protective against gastroenteritis?

A 
Breast feeding
Rotavirus vaccine (given orally at 2 and 3 months of age)
65
Q

What is gastro-oesophageal reflux?

A

Non-forceful regurgitation of milk and other gastric contents into the oesophagus

66
Q

What is possetting? Is it concerning?

A

= Asymptomatic effortless regurgitation of a small quantity of milk after a feed

Normal in young infants and doesn’t need any investigations / treatment

67
Q

When does GOR become GORD?

A

GORD = persistent, more frequent reflux that gives rise to troublesome symptoms or complications

68
Q

How common is GOR in infancy?

A

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
Q

What are some risk factors for GOR in children? (7)

A

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
Q

How may GOR present in children?

A

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
Q

How is a diagnosis made of GOR?

A

Majority clinically

72
Q

What is laryngopharygneal reflux (LRD) in children?

A

LRD = reflux into larynx, oropharnyx and/or nasopharynx

73
Q

What is LRD associated with? (7)

A

1) FTT
2) Laryngomalacia
3) Recurrent respiratory papillomatosis
4) Chronic cough
5) Hoarseness
6) Oesphagitis
7) Aspiration

74
Q

When is LRD suspected? How is it confirmed?

A

Diagnosis based on high index of suspicion if there are no symptoms specially indicating GOR

Confirmed using endoscopy, pH probes and radiography

75
Q

What does frequent, projectile vomiting in infants up to 2 months old suggest?

A

Pyloric stenosis

76
Q

What does bile-stained (green or yellow/green) vomit suggest?

A

Intestinal obstruction

77
Q

What does haematemesis suggest? What is important to ask about?

A

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
Q

What does onset of regurgitation and/or vomiting after 6 months of age and persisting after 1yr suggest?

A

Cause other than reflux eg UTI

79
Q

What does vomiting + blood in stools suggest?

A

Bacterial gastroenteritis, infant’s cow’s milk protein allergy or acute surgical condition

80
Q

What does abdo distension, tenderness or palpable mass suggest?

A

Acute surgical condition

Obstruction

81
Q

What does chronic diarrhoea suggest?

A

Cow’s milk protein allergy

82
Q

What does vomiting + bulging fontanelle suggest?

A

Raised ICP eg meningitis

83
Q

What does vomiting + dysuria suggest?

A

UTI

84
Q

What does a rapidly increasing head circumference (>1cm/week) or persistent morning headache and vomiting worse in the morning suggest?

A

Raised ICP eg due to hydrocephalus or a brain tumour

85
Q

Infants and children with a high risk of atopy + vomiting are more likely to have what?

A

Cow’s milk protein allergy

86
Q

GOR does not usually need investigating. What investigations are performed in more serious cases of GOR?

A

1) FBC
2) 24hr ambulatory oesophageal pH study
3) Barium meal
4) Endoscopy
- If oeophagitis suspected
5) Mamometry

87
Q

What would a 24hr ambulatory oesophageal pH study show in GOR?

A

Frequent dips in pH <4

88
Q

What is a barium meal used for when investigating in GOR?

A

To exclude underlying abnormalities in oesophagus, stomach and duodenum other than GORD

89
Q

When is an upper GI contrast study required urgently?

A

Unexplained bile-stained vomitting or dysphagia

90
Q

What is the lifestyle management of GOR?

A
  • Reassurance it is normal and most grow out of it by 1yr

- Positioning when g

91
Q

What is the lifestyle management of GOR?

A
  • 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
Q

What medications may be offered in GOR?

A

Antacids
H2 receptor antagonists
PPIs

(specialist advice)

93
Q

When should surgery be considered in children with GORD?

A

Required if severe, intractable GORD where management proves impractical eg long term, continuous, thickened enteral feeding

94
Q

What surgery may rarely be required in GOR? When may it be required?

WHAT IS

A

Nissens funcoplication / lap fundoplication

  • upper part of stomach is wrapped around LES to strengthen and prevent reflux
95
Q

What are some complications of GOR? (4)

A

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
Q

What features may be apparent in a child with recurrent reflux persisting later in childhood? (4)

A

Chronic cough
Wheeze
Clubbing
Recurrent pneumonias

97
Q

What conditions are associated with GOR? (4)

A

Cerebral palsy
Down’s syndrome
Developmental delay
Sandifer’s syndrome

98
Q

Are you concerned about bilious vomit?

A

YES - INTESTINAL OBSTRUCTION UNTIL PROVEN OTHERWISE

99
Q

What is important to ask about in a vomiting hx

A

Vomiting:

  • Bilious / non-bilious
  • Colour
  • Consistency
  • Volume
  • Nature

Growth/weight loss
Eating and drinking
Bowel habit

100
Q

What are some red flags in a vomiting hx? (3)

A

Bile stained vomiting
Projectile vomiting
Haematemesis

101
Q

What is important to assess when examining a child presenting with vomiting?

A 
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
Q

What does an ‘olive mass’ indicate?

A

Pyloric stenosis

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