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Yr 4 - Paediatrics > GI: Constipation & GORD > Flashcards

GI: Constipation & GORD Flashcards

1
Q

What is non-organic or functional abdominal pain?

A

This is where no disease process can be found to explain the pain.

It is very common in children >5.

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2
Q

What are some medical causes of abdo pain in both sexes?

A
  • Constipation
  • UTI
  • Coeliac disease
  • IBD & IBS
  • Mesenteric adenitis
  • Abdominal migraine
  • Pyelonephritis
  • Henoch-Schonlein purpura
  • Tonsilitis
  • DKA
  • Infantile colic
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3
Q

What are some additional medical causes of abdo pain in girls?

A
  • Dysmenorrhoea
  • Mittelschmerz (ovulation pain)
  • Ectopic
  • PID
  • Ovarian torsion
  • Pregnancy
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4
Q

What are 4 surgical causes of abdo pain?

A

1) Appendicitis

2) Intussusception

3) Bowel obstruction

4) Testicular torsion

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5
Q

Describe abdo pain in intussusception

A

Causes colicky non-specific abdominal pain with redcurrant jelly stools.

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6
Q

Describe pain in testicular torsion

A

Causes sudden onset, unilateral testicular pain, nausea and vomiting

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7
Q

What are some red flags for serious abdo pain?

A
  • Persistent or bilious vomiting
  • Severe chronic diarrhoea
  • Fever
  • Rectal bleeding
  • Weight loss or faltering growth
  • Dysphagia (difficulty swallowing)
  • Nighttime pain
  • Abdominal tenderness
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8
Q

What investigations may be relevant for a child with abdo pain?

A

1) FBC: anaemia (IBD or coeliac disease)

2) ESR & CRP: IBD

3) Raised anti-TTG or anti-EMA antibodies: Coeliac disease

4) Raised faecal calprotectin: IBD

5) Urine dipstick: UTI

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9
Q

What does recurrent (functional) abdo pain often correspond to?

A

Stressful life events e.g. loss of a relative, bullying.

The leading theory for the cause is increased sensitivity and inappropriate pain signals from the visceral nerves (the nerves in the gut) in response to normal stimuli.

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10
Q

Management of functional abdo pain in a child?

A

Distracting the child from the pain with other activities or interests

Encourage parents not to ask about or focus on the pain

Advice about sleep, regular meals, healthy balanced diet, staying hydrated, exercise and reducing stress

Probiotic supplements may help symptoms of irritable bowel syndrome

Avoid NSAIDs such as ibuprofen

Address psychosocial triggers and exacerbating factors

Support from a school counsellor or child psychologist

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11
Q

What is an abdominal migraine?

A

This may occur in young children before they develop traditional migraines as they get older.

Abdominal migraine presents with episodes of central abdominal pain lasting more than 1 hour.

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12
Q

What other symptoms may an abdominal migraine be associated with?

A
  • N&V
  • Anorexia
  • Pallor
  • Headache
  • Photophobia
  • Aura
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13
Q

Management of an acute abdominal migraine attack?

A

Similar to management of migraine in adults.

1) Low stimulus environment (quiet, dark room)
2) Paracetamol
3) Ibuprofen
4) Sumatriptan

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14
Q

What 4 medications does preventative management of abdominal migraine involve?

A

1) Pizotifen, a serotonin agonist

2) Propranolol, a non-selective beta blocker

3) Cyproheptadine, an antihistamine

4) Flunarazine, a calcium channel blocker

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15
Q

What is the 1st line preventative medication to remember for abdominal migraine?

A

Pizotifen

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16
Q

Important note regarding treatment with pizotifen?

A

It needs to be withdrawn slowly when stopping as it is associated with withdrawal symptoms such as depression, anxiety, poor sleep and tremor (as is a serotonin agonist).

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17
Q

What are some symptoms of constipation in children?

A
  • Abdominal pain
  • Fewer than 3 complete stools per week
  • Hard stools that are difficult to pass
  • ‘Rabbit droppings’ (type 1)
  • Overflow soiling (commonly very loose, very smelly, stool passed without sensation)
  • Distress on passing stool, straining
  • Bleeding associated with hard stool
  • Evidence of retentive posturing: typical straight-legged, tiptoed, back arching
  • Previous or current anal fissure

-Loss of the sensation of the need to open the bowels

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18
Q

What is encopresis?

A

The term for faecal incontinence.

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19
Q

At what age is encopresis considered pathological?

A

≥4 years old

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20
Q

What are some causes of constipation in children?

A
  • Idiopathic
  • Dehydration
  • Low fibre diet
  • Medications e.g. opiates
  • Anal fissure
  • Over enthusiastic potty training
  • Hypothyroidism
  • Hypercalcaemia
  • Hirschsprung’s disease
  • Learning disabilities
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21
Q

What are some causes of encopresis?

A
  • Chronic constipation (The rectum becomes stretched and looses sensation. Large hard stools remain in the rectum and only loose stools are able to bypass the blockage and leak out, causing soiling).
  • Spina bifida
  • Hirschprung’s disease
  • Cerebral palsy
  • Learning disability
  • Psychosocial stress
  • Abuse
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22
Q

What are some lifestyle factors that can contribute to the development and continuation of constipation?

A
  • Habitually not opening the bowels
  • Low fibre diet
  • Poor fluid intake and dehydration
  • Sedentary lifestyle
  • Psychosocial problems such as a difficult home or school environment (always keep safeguarding in mind)
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23
Q

What is desensitisation of the rectum?

A

Often patients develop a habit of not opening their bowels when they need to and ignoring the sensation of a full rectum.

Over time they lose the sensation of needing to open their bowels, and they open their bowels even less frequently.

They start to retain faeces in their rectum. This leads to faecal impaction, which is where a large, hard stool blocks the rectum.

Over time the rectum stretches as it fills with more and more faeces.

This leads to further desensitisation of the rectum. The longer this goes on, the more difficult it is to treat the constipation and reverse the problem.

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24
Q

What are some 2ary causes of constipation in children?

A
  • Hirschsprung’s disease
  • Cystic fibrosis (particularly meconium ileus)
  • Hypothyroidism
  • Spinal cord lesions
  • Sexual abuse
  • Intestinal obstruction
  • Anal stenosis
  • Cows milk intolerance
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25
Q

What are the ‘red flag’ vs idiopathic features of constipation in children regarding ‘timing’?

A

Idiopathic:
- Starts after a few weeks of life
- Obvious precipitating factors e.g. fissure, change of diet, timing of potty/toilet training or acute events such as infections, moving house, starting nursery/school, fears and phobias, major change in family, taking medicines

Red flag:
- Reported from birth or first few weeks of life

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26
Q

What are some ‘red flag’ features of constipation in children?

A
  • Reported from birth or first few weeks of life
  • Passage of meconium >48 hours
  • ‘Ribbon’ stools
  • Faltering growth (amber flag)
  • Previously unknown or undiagnosed weakness in legs, locomotor delay
  • Abdo distension
  • Disclosure or evidence that raises concerns over possibility of child maltreatment
  • Vomiting
  • Abnormal lower back or buttocks (spina bifida, spinal cord lesion or sacral agenesis)
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27
Q

What 2 conditions may not passing meconium within 48 hours of birth indicate?

A

CF or Hirschsprung’s disease

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28
Q

What is a ribbon stool?

A

When stool appears thin or narrow, often resembling strips of ribbon.

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29
Q

What can ribbon stool in infants indicate?

A

Anal stenosis

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30
Q

What is Hirschsprung’s disease?

A

Caused by an aganglionic segment of bowel due to a developmental failure of the parasympathetic Auerbach and Meissner plexuses.

Possible presentations:
- neonatal period e.g. failure or delay to pass meconium
- older children: constipation, abdominal distension

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31
Q

What may vomiting associated with constipation in children indicate?

A

Intestinal obstruction or Hirschsprung’s disease

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32
Q

What may failure to thrive associated with constipation in children indicate?

A

Coeliac disease, hypothyroidism or safeguarding.

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33
Q

What may an abnormal anus associated with constipation indicate?

A

Anal stenosis, inflammatory bowel disease or sexual abuse.

34
Q

What are some complications of constipation in children?

A

Pain
Reduced sensation
Anal fissures
Haemorrhoids
Overflow and soiling
Psychosocial morbidity

35
Q

Prior to starting treatment for constipation, what does the child need to be assessed for?

A

Faecal impaction

36
Q

What are some factors that suggest faecal impaction?

A
  • symptoms of severe constipation
  • overflow soiling
  • faecal mass palpable in the abdomen (digital rectal examination should only be carried out by a specialist)
37
Q

1st line management if faecal impaction is present?

A

Disimpaction regimen with high doses of laxatives at first –> Polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain), using an escalating dose regimen.

38
Q

What type of laxative is Polyethylene glycol 3350 (Movicol Paediatric Plain)?

A

Osmotic

39
Q

2nd line management of faecal impaction if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks?

A

Add a stimulant laxative

40
Q

What is the 1st line laxative for the management of constipation in children?

A

Movicol (osmotic laxative).

Also ensure adequate fluid and fibre intake, consider regular toileting and non-punitive behavioural interventions.

41
Q

Is constipation more common in breast or bottle-fed infants?

A

Bottle-fed

Note - constipation in breast-fed infants is unusual and organic causes should be considered

42
Q

management of constipation in bottle fed infants?

A

Give extra water in between feeds. Try gentle abdominal massage and bicycling the infant’s legs

43
Q

Regurgitation of feeds occurs in what % of infants?

A

Up to 40% (very common).

It usually begins before 8 weeks old and will resolve before they turn one year old.

44
Q

What is GORD?

A

Where contents from the stomach reflux through the lower oesophageal sphincter into the oesophagus, throat and mouth.

45
Q

Why is it common for babies to reflux feeds?

A

As there is immaturity of the lower oesophageal sphincter, allowing stomach contents to easily reflux into the oesophagus.

It typically resolves by 1-year-old as the sphincter naturally strengthens.

46
Q

What age does reflux of feeds typically stop by?

A

1 year

47
Q

What is the commonest cause of vomiting in infancy?

A

GORD

48
Q

What are some risk factors for GORD in infants?

A

1) Prematurity

2) History of congenital diaphragmatic hernia or oesophageal atresia

3) Hiatus hernia

4) Neurodisability (e.g. cerebral palsy)

5) Parental history of heartburn or acid regurgitation

49
Q

What are some anatomical and physiological features that contribute to GORD in infants?

A
  • Short, narrow oesophagus
  • Delayed gastric emptying
  • Shorter, lower oesophageal sphincter that is slightly above the diaphragm
  • Liquid diet and high calorie requirement, distending the stomach and increasing pressure gradient between stomach and oesophagus
  • Larger ratio of gastric volume to oesophageal volume
  • Spending significant periods recumbent
50
Q

It is important and can be challenging to distinguish between GOR and GORD in infants.

What symptoms can you ask about?

A
  • Distressed behaviour (eg. excessive crying, unusual neck postures, back-arching)
  • Unexplained feeding difficulties (refusing feeds, gagging, choking)
  • Hoarseness and/or chronic cough in children
  • Pneumonia
  • Faltering growth
  • If child is able to they may report retrosternal or epigastric pain

Children over one year may experience similar symptoms to adults, with heartburn, acid regurgitation, retrosternal or epigastric pain, bloating and nocturnal cough.

51
Q

It is important to take a full feeding history for children with suspected GORD.

What should this involve?

A
  • Check position, attachment, technique, duration, frequency and type of milk.
  • Calculate the volume of milk being given as babies can be over-fed and therefore have gastric over-distension.
  • Ask about frequency and estimated volume of vomits
  • Find out the relationship of symptoms to feeds.
52
Q

What should exam involve in potential child with GORD?

A
  • Hydration status
  • Signs of malnutrition
  • Any abnormalities that may indicate a differential diagnosis e.g. atopy with feed intolerance may point to cow’s milk protein allergy.
  • Assess growth charts to look for faltering growth.
53
Q

What are some causes of vomiting in infants?

A
  • Overfeeding
  • GORD
  • Pyloric stenosis (projective vomiting)
  • Gastritis or gastroenteritis
  • Appendicitis
  • Infections such as UTI, tonsillitis or meningitis
  • Intestinal obstruction
  • Bulimia
54
Q

GOR vs GORD?

A

Gastro-oesophageal reflux (GOR) is the passage of gastric contents into the oesophagus and is normal in infants if it is asymptomatic.

Gastro-oesophageal reflux disease (GORD) is the term used to describe this process in the presence of symptoms or complications from the reflux.

55
Q

What are some red flags in a GORD history that should make you think about serious underlying problems?

A
  • Not keeping down any feed (pyloric stenosis or intestinal obstruction)
  • Projectile or forceful vomiting (pyloric stenosis or intestinal obstruction)
  • Bile stained vomit (intestinal obstruction)
  • Haematemesis or melaena (peptic ulcer, oesophagitis or varices)
  • Abdominal distention (intestinal obstruction)
  • Reduced consciousness, bulging fontanelle or neurological signs (meningitis or raised intracranial pressure)
  • Respiratory symptoms (aspiration and infection)
  • Blood in the stools (gastroenteritis or cows milk protein allergy)
  • Signs of infection (pneumonia, UTI, tonsillitis, otitis or meningitis)
  • Rash, angioedema and other signs of allergy (cows milk protein allergy)
  • Apnoeas are a concerning feature and may indicate serious underlying pathology and need urgent assessment
56
Q

In simple cases of GORD some explanation, reassurance and practical advice is all that is needed.

What advice should you give?

A
  • Smaller, more frequent meals
  • Burping regularly to help milk settle
  • Not over-feeding
  • Keep the baby upright after feeding (i.e. not lying flat)
57
Q

If the infant is breastfed with frequent regurgitation causing marked distress, what is the management step?

A

Use alginate (e.g. Gavisocon) mixed with water immediately after feeds.

58
Q

If the infant is formula-fed with frequent regurgitation causing marked distress, what is the management?

A

Stepwise approach:

1) Ensure infant is not over-fed (no more than 150ml/kg/day total milk)

2) Decrease feed volume by increasing frequency (eg. 2-3 hourly)

3) Use feed-thickener (or pre-thickened formula)

4) Stop thickener and start alginate added to formula

59
Q

For both bottle and breastfed infants with marked GORD, if there is no response to alginate therapy after a 2 week trial, what can be given?

A

PPI or histamine antagonist (e.g ranitidine).

If symptoms persist refer to paediatrics and reconsider differential diagnosis

60
Q

What are some (uncommon) complications of GORD in infants?

A
  • Reflux oesophagitis
  • Recurrent aspiration pneumonia
  • Recurrent acute otitis media (>3 episodes in 6 months)
  • Dental erosion (especially in children with neurodisability)
  • Apnoea (rare)
61
Q

What is Sandifer’s syndrome?

A

A rare condition causing brief episodes of abnormal movements associated with gastro-oesophageal reflux in infants. The infants are usually neurologically normal.

The condition tends to resolve as the reflux is treated or improves.

62
Q

What are the 2 key features of Sandifer’s syndrome?

A

1) Torticollis
2) Dystonia

63
Q

What is torticollis?

A

forceful contraction of the neck muscles causing twisting of the neck

64
Q

What is dystonia?

A

abnormal muscle contractions causing twisting movements, arching of the back or unusual postures

65
Q

What is cow’s milk protein allergy (CMPA)?

A

An immune-mediated allergic response to naturally-occurring milk proteins casein and whey

66
Q

How can CMPA be classified?

A

According to the aetiology: IgE-mediated, non-IgE-mediated, and mixed.

67
Q

What is IgE-mediated CMPA?

A

A type-I hypersensitivityreaction.

CD4+ TH2 cells stimulate B cells to produce IgE antibodies against cow’s milk protein which trigger the release of of histamine and other cytokines from mast cells and basophils.

68
Q

What is non-IgE-mediated CMPA?

A

Involves T cell activation against cow’s milk protein

69
Q

What are risk factors for CMPA?

A

1) Personal history of atopy (eg. asthma, eczema, allergic rhinitis, other food allergies)

2) Family history of atopy (only allergic predisposition is inherited, not specific allergies)

Note - Exclusively breastfeeding is a protective factor.

70
Q

Is CMPA seen more frequently in breast or bottle-fed infants?

A

Bottle-fed

71
Q

Features of CMPA?

A

GI:
- regurgitation and vomiting
- diarrhoea
- bloating & wind
- abdo pain
- ‘colic’ symptoms: irritability, crying

Allergic:
- urticaria, atopic eczema
- wheeze, chronic cough
- rarely angioedema and anaphylaxis may occur

72
Q

How can speed of onset of symptoms help to differentiate between IgE and non-IgE-mediated CMPA?

A

IgE-mediated: Acute and frequently has a rapid onset (up to 2 hours after ingestion)

Non-IgE-mediated: Non-acute and generally delayed (manifest up to 48 hours or even 1 week after ingestion)

73
Q

Who is it also important to consider CMPA in?

A

In patients with atopic eczema, gastro-oesophageal reflux disease or chronic gastrointestinal symptoms who are not responding adequately to treatment.

74
Q

What age does CMPA typically affect?

A

<3 y/o

75
Q

How is a diagnosis of CMPA made?

A

The diagnosis is made based on a full history and examination.

Skin prick testing can help support the diagnosis but is not always necessary.

Can use total IgE and specific IgE (RAST) for cow’s milk protein.

76
Q

Management of CMPA?

A

Avoiding cow’s milk should fully resolve symptoms:

  • Breast feeding mothers should avoid dairy products
  • Replace formula with special hydrolysed formulas designed for cow’s milk allergy
77
Q

What age should children grow out of CMPA?

A

Most children will outgrow cow’s milk protein allergy by age 3, often earlier.

Every 6 months or so, infants can be tried on the first step of the milk ladder (e.g. malted milk biscuits) and then slowly progress up the ladder until they develop symptoms. Over time they should gradually be able to progress towards a normal diet containing milk.

78
Q

Cow’s milk intolerance vs CMPA?

A

Cow’s milk intolerance presents with the same gastrointestinal symptoms as cow’s milk allergy (bloating, wind, diarrhoea and vomiting), however it does NOT give the allergic features (rash, angio-oedema, sneezing and coughing).

Infants with cow’s milk allergy will not be able to tolerate cow’s milk at all, as it causes an allergic reaction, whereas infants with cow’s milk intolerance will be able to tolerate and continue to grow and develop, but will suffer with gastrointestinal symptoms whilst having cow’s milk.

79
Q

What is infantile colic?

A

A relatively common and benign set of symptoms seen in young infants (<3 months old).

Characterised by bouts of excessive crying and pulling-up of the legs, often worse in the evening.

Cause is unknown.

80
Q
A

Yr 4 - Paediatrics (78 decks)

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