Gi Disorders Flashcards
What is posseting
Non forceful return of milk in small amounts often with return of swallowed air
Difference between Regurgitation and posseting
Regurge is larger more frequent losses.
All babies get posseting but Regurge indicates GORD
When to investigate vomiting
Prolonged, Bilous, systemically unwell or failing to thrive
Bile stained vomit ->
?intestinal obstruction
Blood stained vomit query
Oesophagitis, ulceration, oral/nasal bleeding, malrotation
Projectile vomiting in first few weeks of life query
Pyloric stenosis
Query If abdominal distension with vomiting
Lower intestinal obstruction (check for strangulated Inguinal hernia )
What factors contribute to GOR in infants
Immature lower oesophageal sphincter
Milk rather than solid food
Supine posture
How many infants with GOR have severe symptoms ? What are they ?
10%
Failure to thrive, oesophagitis, recurrent aspiration pneumonia
Who is GOR most serve in
Infants with chronic lung disorders (eg. Bronchopulmonary dysplasia), cerebral palsy & neurodevelopmental problems
Investigation for GOR
24hr ambulatory oesophageal pH monitoring - gold standard in older children Barium studies (anatomical abnormalities) Endoscopy in suspected oesophagitis
Management of GOR
Reassurance most cases
Prokinetic drugs DOMPERIDONE - increase gastric emptying and decrease pressure on LOS
Decrease acid secretion - H2 antagonists /PPIs
Incidence of pyloric stenosis and cause ?
Who gets more ?
1-5/1000
Hyper trophy of pyloric smooth muscle
Males 5x
FHx common - especially maternal
Features of pyloric stenosis ? When do features not occur ?
Persistent, projectile non-bilious vomiting between 2 and 6 weeks old. Infant appears worried, hungry and eager to feed after vomit
Doesn’t occur in newborn or beyond 3/12
Signs of pyloric stenosis
Visible peristalsis and palpable pyloric mons during test feed
How is a diagnosis of pyloric stenosis made
USS abdomen - confirms diagnosis by showing hypertrophic pylorus
Classic electrolyte disturbance -> metabolic alkalosis (elevated serum HCO3-)
Management of pyloric stenosis
Medical - correction of fluid and electrolyte abnormalities
Surgical - pyloromyoectomy (romsteats procedure)
What is gastroenteritis and how does it present
Infection of GI tract (usually viral)
Diarrhoea and vomiting
Pathogens causing gastroenteritis ? Most common?
Rotavirus - most common
Bacteria - shigella, salmonella, campylobacter ssp., E. coli
Parasites - entamoeba histolytica, giardia lamblia, cyptosppridium ssp.
Features of viral gastroenteritis
Prodromal infection followed by d&v
Vomiting may precede D and is not usually bile / blood stained
What suggests a bacterial gastroenteritis
Abdominal pain and blood / mucus in the stool (invasive pathogen)
What do you need to differentiate gastroenteritis form ? What is assessed and how do you make a diagnosis?
Pyloric stenosis & intussuseption
Assess dehydration and measure U&E’s
Stool culture & microscopy , stool viral antigen detection
3 levels of dehydration
Mild
Moderate 5-10% weight loss
Severs >10% weight loss
Features of mild dehydration
Dry mucous membranes, fewer wet nappies
Signs of moderate dehydration
Sunken eyes and fontanelle, decreased skin turgor, deep respiration, rapid weak pulse, decreased /absent tears
Signs of severe dehydration
Low BP, drowsy, cool, cyanotic extremities, deep and rapid respiration, tachycardia, weak pulses, prolonged cap refil
When should oral rehydration be bypassed and straight to IV
Signs of circulatory failure
What’s given for oral rehydration ? How do they work
Solutions eg. Dioralyte, rehidrat
Contain dextrose to stimulate sodium and water reabsorbtion across bowel wall
What characterises infantile colic ? How often does this happen and at what age?
Recurrent inconsolable crying accompanied by drawing up of the legs.
Several times / day especially in evening
Begins at 2 weeks and resolves by 4/12
What are the differentials for infantile colic
Colic, otitis media, incarcerated hernia, uti, anal fissure, intussusception
What can sometimes cause infantile colic
GOR / cows milk protein intolerance
How to diagnose infantile colic
Rule out DDs
Management of infantile colic
No interventions proven effective
Benign condition with good prognosis
DDs for acute abdomen
Appendicitis, intussusception, merkels diverticulum, mesenteric adenitis, malrotation with volvulus
4 extra abdominal causes of acute abdomen
Lower lobe pneumonia - referred pain to abdo
Primary peritonitis - seen with ascities from nephrosis / liver disease
DKA - cause abdo pain
UTI (inc pyelonephritis)
Usual cause of appendicitis
When gets obstructed by faecolith or inflamed by lymphatic hyperplasia
Symptoms of appendicitis
Anorexia (decreased appetite), vomiting (usually only few times)
Abdominal pain - central and colicky -> localises to RIF
Signs of appendicitis
Mid - low grade fever - 37.2-38
Tachycardia
Persistent tenderness and guarding at RIF
DDs of appendicitis
Surgical - Intussusception, volvulus, strangulated hernia, ovarian torsion
Medical - mesenteric adenitis, gastroenteritis, uti, lower lobe pneumonia, DKA, sickle cell crisis
Management of appendicitis
Appendectomy
What is meckels diverticulum
Remnant of the fetal Vitello-intestinal duct
What is the rule of 2s with meckels diverticulum
2% of people, 2 inches long, 2 feet proximal to ileoceacal value
What’s contained in meckels diverticulum
Ectopic gastric mucosa or pancreatic tissue
Features of meckels diverticulum
Most asymtomatic
May present with severe PR bleeding which is neither bright red or true malaena
How may meckels present
Intussusception, volvulus around a bend or diverticulitis
Diagnosis of meckels
Technetium scan - will demonstrate increased uptake by gastric mucosa in -70%
Treatment of meckels
Surgical resection
What is intussusception
Invagination of proximal bowel into distal segment
Where does intussusception usual,y occur and at what age?
Just proximal to ileoceacal valve
6-9/12
What is the classic train of intussusception? What’s a late sign ?
1- paroxysmal, colicky abdominal pain
2- vomiting - may be bile stained
3- sausage shaped abdo mass (usually in R upper quadrant)
Red currant jelly stools
Diagnosis of intussusception
AXR- distended small bowel and absence of gas in distal colon
Uss - target sign (donut sign)
Management of intussusception
Reduction by AIR ENEMA
When is an air enema contraindicated
Long Hx 24-48hrs or if there are signs of intestinal obstruction, peritonitis or shock
What happens if air enema is unsuccessful
Operative reduction
What is mesenteric adenitis
Non specific inflammation of mesenteric lymph nodes - thought to provide a peritoneal reaction that causes abdo pain (may mimic appendicitis )
Features of mesenteric adenitis
Less severe pain than appendicitis and tenderness in RIF is variable
Often accompanied by URTI and cervical lymphadenopathy
May have systemic - fever, headache, pharyngitis
Management of mesenteric adenitis
Non specific abdo pain is a worry - may require hospital observation
Persisting RIF tenderness warrants surgical exploration to identify appendicitis
What predisposes to volvulus and why
Small bowel mesentery not fixed at duodenal-jejunal flexure / ileoceacal region then its base is shorter than normal
What is the commonest form of malrotation
When caecum remains high and fixed to posterior abdominal wall - Ladd’s bands may cross the duodenum contributing to obstruction
Features of malrotation
Obstruction
Obstruction with compromised blood supply
What happens if obstruction causes an obstructed blood supply
Bowel infarction -> may be blood in gastric aspirates or in stool
What may happen in first 1-3 days of life that could indicate volvulus and what should be done ?
Dark green Bilous vomiting
Urgent upper GI contrast study
Management of malrotation / volvulus
Surgical correction
Food intolerance more common in who
Strong FHx of atopy of IgA deficiency
How does food intolerance present
Protracted diarrhoea (+/- vomiting) and failure to thrive
Eg of some food intolerances
Cows milk, soya, wheat, fish, egg, chicken, rice, nuts
How to diagnose food intolerance
Removal of food -> cures
Bring back -> brings on Sx
What can cows milk protein intolerance cause
Protein losing enteropathy and blood loss
How is cows milk protein intolerance managed
Casein-hydosylate based formula as 30% also will have / develop soya intolerance
What is a common cause of lactose intolerance
Lactase deficiency
Cause of lactase deficiency
Post gastroenteritis , or primary in afro Caribbean / oriental
Why does lactase deficiency cause lactose intolerance
Leads to sugar accumulation in bower -> watery diarrhoea
Bacterial acid production lowers stool pH -> excoriation (sore / red) perianal region
What part of gluten causes immunological response in coeliac
Gliardin
What changes occur in coeliac
Atrophy of villi and crypt hyperplasia -> reduced absorption surface
Genetic association for coeliac
HLA DQ2
Most common features of coeliac
Anaemia (iron or folate), diarrhoea, ataxia, irritability, growth failure
How do some children with coeliac present when weaning
Failure to thrive (rare and Steatorrhoea occurs first)
Examination findings for coeliac
Poor weight gain, abdominal distension, buttock wasting
Most common cause of loose stools in preschool children
Toddler diarrhoea (chronic non specific diarrhoea)
Features of toddler diarrhoea
Variable consistency and common presence of undigested vegetables ( peas and carrots diarrhoea)
What is important in toddler diarrhoea
Child is well and thriving
There is no precipitating dietary factors
Prognosis of toddler diarrhoea
Outgrow by 5 years
May have delay in feacal continence
Screening test for coeliac
Specific IgA antigliardin or antiendomysial antibodies
Diagnosis of coeliac
Jejunal biopsy (flat) followed by improvement on gluten being removed from diet
Management of coeliac
Life long gluten free
Identification of other autoimmune associated
What autoimmune conditions are associated with coeliac
Thyroid
Pernicious anaemia
What has increased risk with coeliac
Small bowel malignancy (especially Lymphoma (t cell))
Is crohns transmural or mucous membrane
Transmural
Most commonly affected place in crohns
Distal ileum and Colin
Histology all hallmark of crohns
Non caseating epitheloid cell granulomata
Features of crohns (most common) ?
Less common?
Abdo pain, diarrhoea and growth failure.
Oral / perianal ulcers
Extra intestinal Sx of crohns
Growth failure, intermittent fever, arthritis, uveitis, erythema nodosum
Diagnosis of crohns
Characteristic changes in barium follow through, colonoscopy and histology (narrowing, fissuring, mucosal irregularities, Mural thickening)
Crohns acute treatment
Steroids
Elemental diet for 6/52
Preventing relapse crohns
Azathiopine
Anti-TNFa (infliximab) as 3rd line
What complications in crohns require surgery
Fistulae, obstruction, medical treatment failure
What layers are affected in UC
Mucus membrane
Features of UC
Rectal bleeding, diarrhoea, colicky pain, weight loss
Diagnosis of UC
Endoscopy - continuous mucosal ulceration
Histology
Extra intestinal features of UC
Erythema nodosum, arthritis, spondylitis, pyoderma gangrenosum
Management of mild UC attacks
Steroids
Extensive UC management
Sulfasalazine
Management of severe fulminating disease in UC
Medical emergency - Brad spec Abx, IV fluids & steroids
Outcome of UC in 1/3
Colectomy
Complications of UC
Increased incidence of adenocarcinoma
Other name for Hirschsprung’s disease
Congential aganglionic mega colon
What is Hirschsprung’s
Absence of myenteric and submucosal plexuses ganglion cells for a variable segment of bowel extending from the anus to colon
What is aganglionic segment of Hirschsprung’s like
Narrow and contracted
Ending proximally in normal segment of dilated and normally inervated colon
Features of Hirschsprung’s in infants
Present in neonatal period with meconium ileus and subsequent Bilous vomiting and abdominal distension due to intestinal obstruction
Features of Hirschsprung’s in older children
Chronic severe constipation present form birth
Abdominal distension & absence of feaces in narrow rectum
Severe life threatening complication of Hirschsprung’s
Hirschsprung’s enterocolitis
Diagnosis of Hirschsprung’s
Barium enema - transition zone where bowel lumen narrows
Definitive (absence of ganglion cells on suction rectal biopsy)
Management of Hirschsprung’s
Surgical resection of affected area -> colostomy -> anastomosis of normal bowel to anus
2 causes of bile duct obstruction in peads
Biliary atresia
Choledochal cyst
What is biliary atresia and how does it present
Destruction / absence of extrahepatic biliary tree
Persistent neonatal jaundice
What type of jaundice in biliary atresia and other feature of jaundice
Predominantly conjugated bilirubin
Pale stools, dark urine
Other features of biliary atresia
Failure to thrive due to malabsorbtion & hepatosplenomegaly
Bleeding disorder due to vit k deficiency
Diagnosis of biliary atresia
Abdominal uss, liver biopsy, intraoperative cholangiography can all be used to confirm
Management of biliary atresia
Kasai procedure (hepatoportoenterostomy) before 6/52 Liver transplant if unsuccessful
What is a choledochal cyst
Cystic dilation of extrahepatic biliary system
Common presentation of choledochal cysts
Infancy with cholestasis
Diagnosis of choledochal cysts
Uss / radionuclide scan
Treatment of choledochal cyst
Surgical excision of cyst and formation of roux-en-Y anastomosis to the biliary duct
Complications of choledochal cyst
2% risk of malignancy (in any part of the biliary tree)
What is not a feature of functional constipation
Pain
How does functional constipation present
Infrequency of stools, difficulty in bowel movements, and stool retention
Treatment for functional constipation
Look for psychological factors (bullying, family stress, uncomfortable school toilets)
Stool softeners - lactulose / docusate
Stimulant laxatives - sodium picosulphate, Senna
What is the functional constipation viscous cycle
Withholding -> megarectum -> worsened constipation with over flow diarrhoea
