GI Disorders in Paeds Flashcards
A 6 month old boy presents to clinic with chronic constipation and abdominal distension.
What do we want to know from PMHx?
- Neonatal period - when was meconium first passed?
- Do they have Down’s syndrome?
- How are they getting on with toilet training? (more older child)
- Diet/exercise? (more relevant in older child)
- Any neurological conditions?
Why is when meconium was first passed a relevant question in constipation?
If they failed to pass any within 48 hours of birth, Hirschsprung’s disease may be the cause.
What is Hirschsprung’s disease?
Absence of parasympathetic ganglion cells in gut, usually in rectum, but may extend into colon -> segments of bowel unable to relax -> functional obstruction.
How can we diagnose Hirschsprung’s disease?
- Clinical diagnosis
- AXR shows distal intestinal obstruction
- Rectal biopsy shows no ganglion cells in submucosa
How do we manage Hirschsprung’s disease?
Surgically - single stage pull through now, or traditional 3 stage procedure (defunctioning colostomy, pull through procedure, and closure of colostomy)
What % of children with Hirschsprung’s disease have good outcome?
75% get normal bowel control.
20% get partial bowel control.
What is the most important complication of Hirschsprung’s disease? Why?
Enterocolitis - it has a 10% mortality
A neonate is examined, and found to have jaundice.
What is our first step to getting a diagnosis?
Establish if it is conjugated or unconjugated bilirubin
A child is brought in with “colicky pains”.
What is colic?
An intermittent pain appearing to come from the abdomen that causes babies to cry periodically throughout the day.
What causes baby colic?
Unknown in cause
A child comes to the GP with their mother because she has noticed her child is not growing very much. After looking in the growth chart, you are also concerned.
What causes of failure to thrive can you think of?
Use a systematic approach.
V - hereditary spherocytosis, thalassaemia
I - IBD, bronchiectasis
T - Child abuse
A - Coeliac disease, hypothyroidism
M - metabolic disease e.g mitochondrial, inborn errors of metabolism
I - Immune deficiency, cow’s milk protein allergy
N
D
I
C/G - ToF, VSD
Other - GORD, CF
What is baby colic defined as?
Distress or crying in an infant which lasts for more than 3 hours a day, more than 3 days a week, for at least 3 weeks in an otherwise healthy infant.
How common is baby colic?
Occurs in 10-30% of infants, affecting male and female equally, and breast-fed and formulla-fed infants equally.
What are some of the risk factors for baby colic?
Smoking/nicotine replacement in pregnancy
Preterm infants
SGA infants
How does baby colic present?
Inconsolable crying, drawing knees up to chest, flatus, and redness of the face.
What elements of a hx of baby colic are important to establish?
- Feeding - breast or bottle
- Weight gain
- Bowel habit
- Vomiting or reflux
- Timing of crying
- Duration of crying
With an acute hx of baby colic, what differentials are there?
- Physical discomfort (cold, wet, hungry)
- Severe nappy rash
- Corneal abrasian
- Intussusception
- Volvulus
- Strangulated hernia
- Testicular torsion
- Non-accidental injury
With an chronic hx of baby colic, what differentials are there?
- Reflux oesophagitis
- Lactose intolerance
- Constipation
- Cow’s milk protein allergy
- Parenting skills/experience of parents
What investigations need to be done for baby colic?
Weight should be checked (normal weight gain is typical for these infants) by hx and examination should be enough.
What S+S would make you suspect another differential for baby colic?
Signs like abnormal weight gain, failure to thrive, or other atypical symptoms.
How are the majority of cases of baby colic managed?
Simple reassurance.
If food intolerance is suspected with baby colic, how can it be managed?
Advise a hypoallergenic diet trial to help identify the allergen.
e.g. cow’s milk protein allergy -> trial completely hydrolysed formula.
Are there any drugs recommended to help with baby colic?
No - simeticone or dicyclomine hydrochloride have no evidence but are unlikely to be harmful.
What is the prognosis like for baby colic?
Excellent - most recover by 3-4 months, even though it is frustrating while it is going on.
How common is constipation in children?
Very - 10-30% of children are affected. It accounts for about 25% of paediatric GI work.
What definitions can be used for constipation in children?
Infrequent defecation, painful defecation, or both.
How infrequent is infrequent defecation?
Fewer than 3 bowel movements per week.
What behaviours might children exhibit when they are constipated?
Retentive posturing
Withholding behaviours
What can chronic constipation cause?
Overflow incontinence i.e. passage of stools in inappropriate places following a period of constipation.
How common is function constipation in children?
90-95% of constipation is functional.
What is functional constipation?
Constipation that does not have a physical or physiological cause. The cause is often psychological, psychosomatic, or neurological.
What social or psychological issues might a child be going through causing constipation?
Bullying
Parental divorce
Sexual abuse
Exam stress
What needs to be asked in a constipation HPC?
- Frequency of defecation
- Consistency of stools
- Episodes of incontinence
- Pain on defecation
- Whether poo block toilet
- Associated behaviours
What can help identify the consistency of a stool from a child?
A visual aid = Bristol Stool Chart
What is pain on defecation likely to lead to?
Withholding
What should be looked for on examination of a child with constipation?
- Abdominal faecal mass
- Inspect of anal stenosis or ectopia
- Sacral abnormalities
Is a rectal examination usually done on a child?
No - it is not necessary and would be too traumatic for a child.
Suggest some organic causes of constipation.
- Anorectal malformations
- Anal fissure
- Rectal prolapse
- Hirschsprung’s (very rarely presents late)
- Neuroenteric problems
- Spinal cord problems
- Metabolic (hypothyroid, coeliac, hypocalcaemia, CF)
- Toxins
- Cow’s milk allergy
In a child under 1 year, how can a diagnosis of constipation be made?
Based on the following criteria - at least 2 of:
- Fewer than 3 complete stools in a week
- Hard rabbit-dropping stools
- Symptoms on defecation
- PMH of constipation
- Previous/current anal fissure
What amber flags may present with constipation?
Faltering growth
Signs of possible maltreatment
What red flags may present with constipation?
- Symptoms start in neonatal period
- Failed/delayed passage of meconium
- Ribbon stools
- Lower neurological signs
- Abdo distension + vomiting
- Abnormalities found on examination
What triggers might be identifiable for constipation?
Weaning
Poor fluid intake
New school
Family problems
How long can constipation treatment take to fully work?
It may take months, especially if there is a behavioural aspect
What are the principles of treating simple constipation in children?
- Reassure
- Lifestyle changes
- Disimpaction
- Maintenance
- Refer if no response after 3 months
What lifestyle advice is given to help treat constipation?
Plenty of fluid, fibre, and exercise.
If an amber flag is present in a hx of constipation, how should it be managed?
-If there is evidence of faltering growth, treat for constipation and test for coeliac disease and hypothyroidism.
-If there is evidence of possible child maltreatment, treat for constipation and refer to guidelines on
suspected child abuse.
If a red flag is present in a hx of constipation, how should it be managed?
Refer immediately for specialist diagnosis and treatment. Do not treat the constipation in primary care.
What issues may need to be targeted when treating functional constipation?
- Anxiety
- Attitudes of guilt or blame
- Inappropriate coercive toilet training
- Social consequences e.g. of foecal incontinence in older children.
How should disimpaction be achieved?
-Use an osmotic laxative initially e.g. Movicol, lactulose
-Adjust the dose as appropriate
-If not tolerated, use stimulant laxative e.g. sodium picosulphate, senna
+- lactulose or faecal softener e.g. docusate
What are the osmotic laxatives?
Movicol (polyethylene glycol)
Lactulose
What are the stimulant laxatives?
Sodium picosulphate
Senna
Bisacodyl
What are the faecal softeners used in children?
Docusate
How often should a child be monitored when treating for disimpaction of constipation?
At least weekly until sucessful
What management is there for constipation maintenance therapy?
- Dietary advice about fibre and fluids
- Regular osmotic laxative to maintain soft stool
- Use of stimulant laxatives intermittently to avoid imoaction
What are osmotic laxatives preferred to stimulants for maintenance therapy for constipation?
Stimulant laxatives long term cause atonic colon and hypokalaemia
What behaviours should be encouraged in children to help prevent constipation?
- Regular, unhurried toileting
- Reward systems for using the toilet successfully
- Linking diary to reward system