GI Disorders in childhood

Question 1

Causes of Abdo Pain

Answer 1

Constipation
Functional/RAP/IBS
Duodenal ulcer/ H. Pylori
IBD

Question 2

GI disorders in children

Answer 2

Constipation
Recurrent abdominal pain (RAP)
Gastritis/duodenal ulcers (DU)
Gastro-oesophageal reflux (GOR)
Rectal bleeding
Inflammatory bowel disease (IBD)
Acute diarrhoea (year 4)
Chronic diarrhoea (year 4)- enteropathy, pancreatic insufficiency, lactase deficiency

Question 3

Causes of chronic vomiting

Answer 3

GOR
Intestinal obstruction
Duodenal ulcers

Question 4

Chronic diarrhoea causes

Answer 4

IBD
Malabsorption + failure to thrive
Constipation

Question 5

Failure to thrive causes

Answer 5

Associated with diarrhoea
Coeliac disease
CF

Question 6

Functional GI disorders

Answer 6

Criteria fulfilled at least once per week for at least 2 months before diagnosis
No evidence for inflammatory, anatomic, metabolic or neoplastic process that explains symptoms

Question 7

Constipation

Answer 7

Infrequent, hard stools or difficulty/delay in defecation, leading to distress
Passing less than 3 stools per week if he/she has painful bowel movements

Question 8

Soiling

Answer 8

Escape of stool into underclothes

Accidental

Question 9

Encopresis

Answer 9

The passage of normal stools in abnormal places

Not accidental

Question 10

Constipation presentation

Answer 10

Diarrhoea
Infrequent bowel movements
Painful bowel movements
Palpable rectal abdominal mass
Acute abdominal pain
Recurrent UTIs

Question 11

Rare Organic causes of constipation

Answer 11

Hirschsprung’s
Hypothyroidism
Neurologic
Anal stenosis

Question 12

Constipation presentation

Answer 12

Distended abdomen
Abnormal anus
Sacral dimples
Palpable rocks in abdomen

Question 13

Constipation investigations

Answer 13

TSH/calcium
Marker studies
Rectal suction biopsy

Question 14

Constipation treatment principles

Answer 14

Initial clear out- high does laxatives/lavage
Maintenance- too much better than too little
One softener, one stimulant

Question 15

Constipation laxatives

Answer 15

Stool Bulking agents
Osmotic laxatives
Stool softeners
Stimulant laxatives
Specific receptor antagonists

Question 16

Stool bulking agents

Answer 16

Fibre supplements e.g. bran
Increase stool bulk by drawing water around their fibres
Require adequate fluid intake

Question 17

Osmotic laxatives

Answer 17

Non-absorbed sugars e.g. lactulose, magnesium and phosphate salts
Draw water into intestinal lumen
May cause dehydration + electrolyte abnormalities

Question 18

Stool softeners

Answer 18

Liquid paraffin
Retained in stool
Ease passage of stools, defecation
Particularly with haemorrhoids + anal fissure

Question 19

Stimulant laxatives

Answer 19

Senna
Stimulate mucosal entero-endocrine cells
–> stimulate motility + fluid secretion

Question 20

Constipation specific receptor antagonists

Answer 20

5HT4 antagonists

Stimulate motility

Question 21

Gastro-oesophageal reflux

Answer 21

Passive regurgitation of gastric/duodenal contents into oesophagus
–> don’t actively contract diaphragm + abdo muscles like vomiting does

Question 22

GORD investigation

Answer 22

pH/impedance studies
Barium swallow
Upper GI endoscopy

Question 23

GORD treatment- medical

Answer 23

Positioning
Thickening of feeds
Reduce acid- H2 antagonists, PPIs
Pro-motility agents e.g. domperidone

Question 24

GORD treatment- surgical

Answer 24

Jejunostomy feeds

Nissen’s fundoplication

Question 25

Eosinophilic Oesophagitis Diagnosis

Answer 25

Treatment- resistant symptoms of GORD History of food sticking History of atopy Required endoscopy to diagnose

Question 26

Eosinophilic Oesophagitis Treatment

Answer 26

Diet- food exclusion Oral budenoside Monteleukast

Question 27

Recurrent abdominal pain definition

Answer 27

1 episode of pain per month for 3 months, sufficient to interfere with routine functioning

Question 28

Gastritis Definition

Answer 28

Inflammation of gastric mucosa H. Pylori infection NSAIDs

Question 29

Gastritis presentation

Answer 29

Vomiting Abdo pain Haematemesis Anaemia

Question 30

H. Pylori

Answer 30

High person to person transmission Clustering in families Higher prevalence in lower socioeconomic classes Often asymptomatic

Question 31

Gastritis Diagnosis

Answer 31

Endoscopy- CLO test, histology Stool antigen C14 urea breath test

Question 32

CLO test (rapid urease test)

Answer 32

Involves inoculation of biopsy specimens into a liquid or gel medium containing urea and phenol red, which turns pink if pH rises above 6.0 - -> change occurs when urea in gel is metabolised to ammonia by the urease of organism - -> red to pink

Question 33

Gastritis treatment

Answer 33

2 weeks- amoxicillin, clarithromycin 6 weeks H2 antagonists/proton pump inhibitors Rapid breath test/stool 3 months after treatment to ensure eradication

Question 34

IBD

Answer 34

Crohn's | Ulcerative Colitis

Question 35

Crohn's disease

Answer 35

Mouth to anus Patchy disease 'skip lesions' Transmural inflammation

Question 36

Ulcerative Colitis

Answer 36

Only rectum/colon Continuous disease (starting from rectum) Mucosal inflammation

Question 37

Crohn's disease presentation

Answer 37

``` Abdominal pain Weight loss Diarrhoea Insidious onset Growth/pubertal delay Fever Clubbing Arthropathy Oral ulcers Abdominal mass ```

Question 38

Crohn's investigations

Answer 38

Raised ESR Raised CRP Low albumin Low Hb

Question 39

Ulcerative colitis presentation

Answer 39

``` Chronic bloody diarrhoea Abdominal pain Weight loss Usually diagnosed within 2 months Sclerosing cholangitis Erythema nodosum Arthropathy ```

Question 40

IBD Diagnosis

Answer 40

Endoscopy + Biopsies --> Upper GI endoscopy: mouth to duodenum --> Ileo-colonoscopy: terminal ileum and anus MRI abdominal

Question 41

IBD treatment- Induce remission

Answer 41

``` Exclusive enteral nutrition --> 6 weeks milk based formula- no food --> Only Crohn's --> reduce inflammation --> correct undernutrition Steroids 5-Aminosaliacylic acid - mesalazine Biologicals- Anti-TNF, infliximab ```

Question 42

IBD treatment- Maintain remission

Answer 42

5-ASA (especially UC) --> pH-dependent coating- dissolves pH>6/7 --> microgranules encased in ethyl cellulose coating --> given as prodrug that is converted into active form by bacterial enzymes- target colon + terminal ileum as bacterial colonies are mainly located there --> once daily dosing Immunosuppressants- Azathioprine Biologicals- Infliximab, adalimumab

Question 43

IBD Surgery

Answer 43

UC- Colectomy, curative of colitis | Crohn's- Depends on disease localisation, likely to need further surgery in future

Question 44

Juvenile polyps- hamartomas

Answer 44

Toddlers Painless rectal bleeding Benign Treatment- excise them