GI and Liver

Question 1

causes of constipation

Answer 1

Acute: dehydration, inadequate fibre intake, bowel obstruction, congenital malformation (atresia), cows milk protein allergy
Chronic: functional constipation, withholding, medications, Hirschsprung’s disease

Question 2

assessment of child with constipation

Answer 2

History: stool consistency, frequency, meconium, associated symptoms? vomiting, signs of infection, any pattern with eating. dietary and medication history important.
examination: plot growth, abdominal exam for hard masses, may need anorectal exam to look for fissures.

Question 3

Management of constipation

Answer 3

increase fibre intake, increase fluid intake.

movicol - can use for 3-6 months, at a stimulant laxative if movicol not working after 2 weeks.

Question 4

prevalence of soiling

Answer 4

3% of children between 4-5, 2% of children between 5-6, 0.1% of those above 10.

Question 5

causes of soiling/encopresis

Answer 5

Developmental: developmental or neurological delay, never learnt to use the toilet
Behavioural: stress, fear
Biological: anal fissure, overflow, severe UC or chrons.

Question 6

Causes of gastroenteritis

Answer 6

most common cause: rotavirus.

other causes: norovirus, shigella (from E.coli), campylobacter, salmonella.

Question 7

Presentation of gastroenteritis

Answer 7

low grade fever and loss of appetite, and vomiting, which will precede the diarrhoea.

Question 8

investigations for gastroenteritis

Answer 8

assess dehydration status

only if prolong or ?bacterial cause do stool culture

Question 9

Management for gastroenteritis? School exclusion? how long should it last for?

Answer 9

fluids -increase intake, ORS, if infant encourage breastfeeding, discourage sugary fruit juice.
no school for 48hrs after the last episode
should recover from 7 days, can last for 2 weeks

Question 10

what is secondary lactose intolerance?

Answer 10

enterocytes in the gut have enzyme lactase, they are lost with D/V and so due to their damage can have secondary lactose intolerance after infection. can last a few months, usually recover.

Question 11

what causes haemolytic uraemic syndrome?

Answer 11

a complication of the shiga toxin, which is produced by some strains of E.coli.

Question 12

what is the presentation of haemolytic ureamic syndrome?

Answer 12

clinically unwell, pale, bruises.

triad of acute renal failure, thrombocytopenia and haemolytic anaemia

Question 13

GORD vs Posseting

Answer 13

GORD: non-forceful regurgitation of gastric contents into oesophagus due to an incompetent sphincter.
posseting: non forceful quantities of milk post feed - normal!

Question 14

Presentation of GORD

Answer 14

can be asymptomatic. recurrent regurgitation, small amounts of vomiting, feeding problems, failure to thrive.
could present with apnoea, cough, or an aspiration pneumonia

Question 15

Assessment of vomiting baby

Answer 15

review feeding routine and volumes
history: colour of vomit, quantity, when it occurs, how often. Growth, feeding and birth history. associated symptoms, (fever, diarrhoea, irritability, melena).
examination: abdominal palpation, hydration status.
Investigations; Ph study for GORD, upper GI study if suspetedmalrotation, bloods: U&Es, blood gas

Question 16

Management of GORD

Answer 16

reassurance - most resolve by 10 months. change feeds to smaller and more frequent.
PPI can be used if indicated.
NG feeds if faltering growth.
surgery if not resolving - Nissen fundoplication.

Question 17

presentation of gastroenteritis caused by adenovirus

Answer 17

cough and cold followed by D/V.

Question 18

Differentials of a vomiting child

Answer 18

GORD, gastroenteritis, overfeeding, pyloric stenosis, malrotation with volvulus,, bowel obstruction, duodenal atresia, systemic infection, intersusseption, paralytic ileus

Question 19

RED flags for vomiting presentation

Answer 19

Bile stained vomit, blood in vomit, drowsiness, signs of dehydration, flattening of growth curve.

Question 20

electrolyte imbalances commonly seen with dehyration

Answer 20

matabolic alkalosis. look at the sodium, potassium, glucose and chloride

Question 21

Fluid bolus for shock management

Answer 21

20ml/kg of 0.9% saline STAT

Question 22

Fluids used for maintenance

Answer 22

0.9% saline with 5% dextrose
100ml for first 10kg
50ml for next 10 kgs
20mls per kg after that.

Question 23

management for replacing fluid losses

Answer 23

1. if shocked give fluid bolus STAT
2. start maintenance fluids
3. replace losses by adding fluid deficit (will be given as a % of dehydration).

Question 24

causes of acute abdominal pain

Answer 24

appendicitis, gastroenteritis, mesenteric adenitis, obstruction, malrotation volvulus, IBD, intersusseption, Henoch-schonlein purpura.
Renal: UTI, hydroneohrosis renal caliculi
other: torsion, ovarian cysts

Question 25

causes or recurrent abdominal pain

Answer 25

peptic ulcer, oesophagitis, IBD, constipation, pancreatitis, PID, dysmenorrhoea, stress.

Question 26

appendicitits: presentation, investigations, management

Answer 26

Presentation: pain moving to RIF, N/V, low grade fever, localised tenderness, Rovsings sign (palpation on LLQ increases pain in RLQ) Investigations: abdominal USS, Bloods (FBC, U&Es, CRP, group and save), urinalysis. Management: laposcopic emergency surgery, with fluids and analgesia

Question 27

pathophysiology of coeliac disease

Answer 27

multigenic disorder, a reaction to the gliadin and glutenins protiens in gluten which causes villous atrophy. this leads to malabsorpition, diarrhoea and poor gowth.

Question 28

presentation of coeliac disease

Answer 28

non specific inflammation. failure to thrive, diarrhoea, vomiting, distended abdomen, muscle wasting, excessive bruising, finger clubbing.

Question 29

investigations for coeliac disease

Answer 29

antibody testing: serum tissue transglutimine type 2, total IA. jejunal biopsy - villous atrophy and crypt hyperplasia Bloods: FBC, LFTs, (elevated transaminases) stool sample

Question 30

complications of coeliac disease

Answer 30

nutritional deficiencies increased risk of bowel cancer and GI lymphoma dermatitis herpetiformis (pruritic itchy skin rash) neurological complications at peripheral neuropathy, cerebella ataxia)

Question 31

ingulinal hernia: direct vs indirect

Answer 31

direct: through the weakness in the posterior wall of the inguinal canal, running inferior and medial to the epigastric vessels - RARE in children indirect: through the internal inguinal ring, running lateral to the inguinal vessels (COMMON in children)

Question 32

risk factors for inguinal hernia

Answer 32

PTB, undescended testes, FH, CF, hip dysplasia, congenital abnormalities

Question 33

presentation of an inguinal hernia

Answer 33

small swelling in the groin or larger swelling in the scrotum. more noticeable when child is straining/coughing/crying. smooth, soft, painless. more common on RHS.

Question 34

complications of irreducible inguinal hernias

Answer 34

strangulation - leading to infarction and loss of the testes.

Question 35

what is intussusception?

Answer 35

when one part of the bowel overlaps inside another part, most commonly occurring in the terminal ileum.

Question 36

when doe intussusception commonly occur?

Answer 36

under 2 years, between 3mo and 6years. most common cause of bowel obstruction in this age group

Question 37

causes of intussusception

Answer 37

viral infection - payers patches inflammation causing the blockage which can move. meckles diverticulum, polps, lymphoma, tumours, CF, HSP.

Question 38

presentation of intussusception

Answer 38

``` paroxysmal pain - colicky severe pain then child sleeps bilious vomiting red-current jelly stool abdominal mass in RUQ pale, dehydrated child. ```

Question 39

management and investigations of suspected intussusception

Answer 39

A-E approach investigations: FBC, U&Es, Abo XR, USS (will show target sign) management: IV fluids, analgesia, antibiotics. emergency surgical intervention or air enema to push bowel back to normal (risk of perforation)

Question 40

signs of abdominal XR an USS for intussusception

Answer 40

XR: round edge of intersusseption with contrast against the lucent lumen of the bowel, air in the bowel USS: target sign, looks like a Pseudokidney.

Question 41

three initial management steps for GORD

Answer 41

1) feeding advise, positional advice 2) feeding thickeners 3) acid blockers (PPI) or motility agents (erythromycin and domperidone)

Question 42

Most common cause of constipation in a child

Answer 42

functional - due to dehydration of low fibre intake

Question 43

treatment for faecal impaction

Answer 43

top down treatment - movicol at a high dose. | 2nd line is an enema

Question 44

Causes of jaundice in children

Answer 44

Pre hepatic: haemolysis, - sickle cell, haemolytic disease of the newborn, gilberts syndorme Hepatic: hepatitis, alpha 1 antitrypsin post hepatic: obstruction of biliary tree, CF.

Question 45

what is conjugated vs unconjugated bilirubin?

Answer 45

conjugated: soluble, metabolised bilirubin (hepatic and post-hepatic causes) unconjugated: insoluble, pre-hepatic causes of jaundice

Question 46

Jaundice history key points

Answer 46

when did it start? how long? ever happened before? BINDS? associated symptoms: malaise, puritus, dark urine, steatorrhea, abdominal tenderness, signs of anaemia - tiredness, breathlessness, pallor

Question 47

complications of jaundice

Answer 47

failure to thrive, kernecitus (bilirubin excess in the CNS)

Question 48

Blood results seen in jaundice: LFTs

Answer 48

Low Hb excess bilirubin ALP raised liver enzymes raised

Question 49

what is mesenteric adenitis? how common is it?

Answer 49

enlargement of intraabdominal lymph nodes, causing abdominal pain. most common cause of abdominal pain in children under15. due to viral or bacterial infection

Question 50

management of mesenteric adenitis

Answer 50

self limiting, will resolve within a few days - 2 weeks. | supportive treatments - fluids, analgesia.

Question 51

presentation of pyloric stenosis, history and examination findings.

Answer 51

projectile non-bilious vomiting, 30 mins after feeding. usually starts within 2 weeks of life. O/E: faltering growth, dehydration, infrequent bowel movements, stomach peristalsis can be seen as well as a lump n RUQ.

Question 52

blood gas of pyloric stenosis

Answer 52

hypokalaemia, hypochloraemic alkalosis

Question 53

investigation for pyloric stenosis

Answer 53

test feed. Bloods: U&Es or VBG - lo k, Na and Cl with a alkalosis. abdominal XR or USS: hyperinflated stomach

Question 54

where do you see the double buble sign?

Answer 54

on an abdominal XR id there is duodenal atresia - showing air before and after te connection.

Question 55

management for pyloric stenosis

Answer 55

Fluid correction , empty stomach with NG. | Surgical management - Ramstad's pyloromyomotomy)

Question 56

presentation of testicular torsion

Answer 56

sudden onset of scrotal or abdominal pain. unilateral red, swollen, oedematous scrotum. absent ceremstric reflex. lifting the testes increases pain associated with N/V

Question 57

who gets testicular torsion?

Answer 57

neonates or adolescents, peak age is 12. most commonly on the LHS

Question 58

two types of testicular torsion? what causes them?

Answer 58

intravaginal - rotation within the tunica vaginalis, lack of normal fixation extravaginal - neonates, just below the inguinal canal, occurs before testes are fixed

Question 59

investigations and management of testicular torsion

Answer 59

A-E approach. Medical emergency investigations: USS doppler to visualise blood flow. Urinalysis to exclude UTI and epididymitis management: analgesia. emergency surgery within 8 hrs to preserve testes.

Question 60

prevalence and risk factors for undescended testes/cryptorchidism

Answer 60

Occurs in 1/300 boys. Usually unilateral. | risk factors: PTB, LBW, FH, SGA, congenital adrenal hyperplasia, prader willi, kalmans syndromes.

Question 61

Management of undescended testes

Answer 61

* If present at birth - review at 6 weeks to see if they have descend. Then review again at 3 months. * If still present at 3 months, will need surgery (gold standard) preferably before 6 months, definitely before 18 months * Alternatively can use hCG or GnRH if it is a low undescended tests, to avoid surgery.

Question 62

What is biliary atresia? how does it present?

Answer 62

inflammation of the extrahepatic bile ducts, causing them to be blocked. three types. presentation: prolonged neonatal jaundice, obstructive jaundice (dark urine, pale stools after a normal meconium), splenomegaly, failure to thrive

Question 63

LFTS in biliary atresia

Answer 63

elevated conjugated bilirubin, elevated transaminases, elevated bile acids and GGT.

Question 64

Management of Biliary atresia

Answer 64

Medical: ursodeoxycholic acid (used to trat gallstones and blockages) to encourage bile flow, vitamin supplementation, prophylactic AbX, nutritional support surgical: only definitive treatment, dissection of abnormalities and anatsamosis creation.

Question 65

causes of biliary atresia

Answer 65

congenital: glutathione S transferase deficiency acquired: autoimmune inflammation, due to viral infection, occurs soon after birth.

Question 66

Presentation of hepatitis

Answer 66

N/C, jaundice, (conjugated), abdominal tenderness, fever, myalgia, puritus.

Question 67

investigations and management of hepatitis

Answer 67

Investigations: Bloods - LFTs, U&Es, Coagulation, FBC. viral serology. liver USS, may need liver biopsy. Management: supportive treatment, flids, analgesia, may need prophylactic abx. antivirals

Question 68

causes of hepatitis

Answer 68

Hep ABCDE, MV, EBV, ESV, VZV, rubella, adenovirus, enterovirus, paravirus, autoimmune

Question 69

Presentation of Hirschprung's disease

Answer 69

Neonates: failure to pass meconium, repeated vomiting. older children: chronic constipation, soiling, abdominal pain, poor growth. could present with acute infection - entercolitis.

Question 70

pathophysiology of Hirschprung's

Answer 70

absence of parasympathetic ganglions in the submucosa of rectum and colon. segments are unable to relax, leading toa functional obstruction.

Question 71

Management of hirschrung's

Answer 71

surgery to remove effected segment. | treat bowel obstruction/infections. IV fluids, NBM, prophylactic Abx.

Question 72

investigations for IBD

Answer 72

faecal calprotien. | endoscopy or colonoscopy.

Question 73

management for IBD

Answer 73

diet: medical: corticosteroids, immunosuppressants, aminosalicylates (eg mezalazine for UC) surgical: resection of inflammation

Question 74

presentation and risk factors of toddlers diarrhoea

Answer 74

foul smelling loose stool with undigested food within. more common with high sugar diet, high fibre and water intake, low fat diet. child is otherwise well and growing normally

Question 75

management of toddlers diarrhoea

Answer 75

plot height and weight. reassurance to parents (common benign condition, due to fast transit through the GI system), cut down fruit juices, normalise feeding patters, limit water intake and high fibre foods.

Question 76

how does malrotation and volvulus occur

Answer 76

malrotaion of the midgut during development (no twisting, mesentry I not attached to the gut in the correct place). due to no mesentry attatchment, the gut is prone to twisting on itself ( a volvulus)

Question 77

presentation of volvulus

Answer 77

bilious vomit, FFT, feeding intolerance, constipation, may have bloody stools, intermittent apnoea. can present collapsd and acutely unwell.

Question 78

investigations with bilious vomiting

Answer 78

A-E approach. volvulus until proven otherwise Bloods: FBC, U&Es Imaging: Upper GI study, abdo XR

Question 79

what are the findings in a upper GI study and an abdo XR with malrotation and volvulus

Answer 79

upper GI study: corkscrew appearance of the jejunum | abdo XR: can show partial obstruction with the double bubble sign

Question 80

management of malrotation and volvulus

Answer 80

A-E assessment. stabilisation | emergency surgery, Ladds procedure

Question 81

how to calculate % fluid deficit

Answer 81

if 10% deficit - need an extra 100mls/kg | if 5% deficit - need an extra 50mls/kg