GI (medical) Flashcards
What is the difference between reflux and reflux disease?
Reflux is just the mechanical symptom of regurgitation of feeds
GORD is when you have negative symptoms that are associated with the reflux
Why is reflux more common in babies?
They have poor tone in their LOS
Spend a lot of time lying down
They have a mostly liquid diet
They have slowed gastric emptying
What are some risk factors for developing GORD?
Pre-term
Hypotonic (for whatever reason including Down Syndrome
Male sex
Cow’s Milk allergy
What are some other common causes of GORD?
Over-feeding - probably the most common cause (parents become worried their baby’s not eating enough because they’re throwing up so they give them more but this actually makes their reflex worse)
Hiatus hernia
Food allergy
CNS disorders
How does GORD commonly present?
Vomiting and regurgitation following feeding Reduced feeding Irritation Weight loss or failure to gain weight Crying Painful swallowing Haematemesis Apnoea, cough, stridor, LRTI (aspiration)
What is Sandifer’s Syndrome?
Bizarre extension and turning of the head and baby’s hold their heads in this position - associated with GORD
What investigations should we do for GORD?
Probably none…it’s a clinical diagnosis
Consider: FBC (anaemia), LFT, 24h Oesophageal pH, Manometry (pressure monitoring), endoscopy
How should GORD be managed?
Usually will self resolve by 10-18 months (weaning children will really help)
POSITIONING really important - keeping infants upright after feeds (putting a head tilt on their cots)
Thickened feeds
Gaviscon, ranitidine and PPIs
What is a potential risk of PPIs in babies?
Small risk of NEC in babies so try and avoid if possible
What is the most common causative agent for gastroenteritis in developed countries? What are some other less common causes?
ROTAVIRUS (60% cases)
Adenovirus, norovirus and coronavirus are also possible causes
What are some common bacterial causes of gastroenteritis and what symptom would make you think it was bacterial over viral?
BLOOD IN STOOL (**in general, clinical features are poor predictors of bacterial vs. viral differentiation)
Campylobacter
Shigella and salmonella
E.coli (strain 0157 particularly associated with blood in stool)
What are some key questions you’d want to ask during the history of a child presenting with gastroenteritis?
OPERATES (onset, progression, exacerbations, relieving, associated symptoms, timing, episodes previously, severity)
Any blood or mucus?
Can you describe what the stool looks like?
How much stool is being passed (dirty nappies per day)
Any contact with infectious persons or foreign travel
Has the child been passing urine normally?
Fever, vomiting, rashes
Has the child been eating and drinking and how much?
What would be some indications for admission in children with gastroenteritis?
Basically these are assessing the dehydration risk (thats the biggest concern)
Poor feeding (<50-75%) Young age (<6m) >6 stools in 24h >3 vomitting episodes in 24h Unable to tolerate malnutrition Clinical signs of dehydration or malnutrition (sunken fontanelle, high central cap refill, sunken features, unwell looking baby, pale)
If you think the child has been considerably dehydrated by their gastroenteritis how are you likely to manage this?
Admit them
Consider NGT placement for re-feeding and fluids
Consider IV access for fluids and also obtain baseline bloods (FBC, U&E, CRP, CBG)
How do we assess the child for clinical signs of dehydration?
WEIGHT is often a really good sign - although unless they’re very young parents probably won’t know weight - weigh anyway for future reference
Assess for following CLINICAL SIGNS
- General appearance, conscious level, urine output, skin (turgor, colour, mottling), extremities (warm or cold), CRT (central), femoral pulses (weak and thready), mucus membranes, heart rate (increased in dehydration), breathing, blood pressure
Which clinical signs specifically would begin to make you worried about shock in dehydration secondary to gastroenteritis?
Pale, cold and mottled skin
Decreased consciousness
Increased CRT
Weak peripheral pulses
Children will only become HYPOTENSIVE at a very late stage (very good at compensating - don’t wait for this clinical sign before treating for shock)
What principle is important when treating children for dehydration and what is this trying to avoid?
TREAT LIKE WITH LIKE
Children can easily become hypotonic if fluid loss is not replaced with isotonic solutions
Why is hyponatraemia particularly bad?
When Na moves from extracellular to intracellular it can lead to influx of water as well meaning the brain volume swells and this can result in convulsions
What investigations should be done for children with gastroenteritis?
Usually none are needed - clinical diagnosis
Can consider doing a stool sample/culture
How should you treat gastroenteritis?
Anti-diarrhoeals not usually indicated
Rehydration therapy is the main objective (oral, NGT or IV) - consider oral rehydration salts e.g. dioralyte
Abx not routinely given only in suspected sepsis, salmonella in under 6/12 and c.diff
What common problem can occur after resolution of gastroenteritis? How should this be managed
Post-gastroenteritis syndrome
- Watery diarrhoea can recur after children return to their normal diet - can sometimes be associated with a temporary lactose intolerance
Simply returning to Oral rehydration salts for 24h should be enough for this to pass by itself
What distinction is it important to make in the history of a baby presenting with ‘vomiting’?
Are they actually vomiting (mechanical regurgitation) or is it just posseting after feeding (happens to all babies, is not worrying)
What other history factors is it important to ask about when a child present with vomiting?
How much are they vomiting (how many episodes and how much per episode)?
What does the vomit look like?
Is it green (bilious)? - CONCERNING
Is there any blood? - CONCERNING
Does it happen at a specific time (after feeding)?
Do they have any other symptoms (of fever, diarrhoea, coryza)
Are they still taking feeds, if so how much?
Are they taking any fluids at all/how much?
Any rashes?
What are some common causes of vomiting in children?
reflux / GORD
Feeding problems / over-feeding
Gastroenteritis
Other infections incl. URTI, OM, Whooping cough
Dietary - Cow’s Milk Protein Intolerance
SURGICAL: pyloric stenosis, atresia, intususscpetion, malrotation, volvulus, strangulated hernia
Inborn errors of metabolism
Congenital adrenal hyperplasia
Renal failure
What causes of vomiting are more common in younger children (<5yo)?
Gastroenteritis Appendicitis Torsion of testes Raised ICP Coeliac disease Renal failure
What causes of vomiting are more common in older children (>5yo)?
Infection Peptic ulceration and h pylori infection Migraine Raised ICP Renal failure DKA Alcohol/drug ingestion Bulimia Pregnancy
What investigations should be done in the child with vomiting?
FBC, U&E, Glucose Baseline observations CBG (metabolic alkalosis in extreme vomiting) UTI - infection screen Full abdominal examination AXR Abdo USS CXR LOTS OF DIAGNOSES CAN BE MADE CLINICALLY
What would some criteria for admission be in a child with vomiting?
Clinical signs of dehydration (increased CRT, cold, clammy, mottled, sunken fontanelle, sunken eyes, tachycardia, increased RR)
Poor observations
Decreased feeding (<50-75% normal)
Young age
***most children will NOT need admission
How should a child with vomiting be managed?
Most will not need admission and you should give advice on feeding and fluid management (making sure they have enough fluids - give water between feeds)
If they need rehydrating consider admission and NGT feeding (IV feeding if serious)
Treatment of underlying cause
What is coeliac disease?
An AUTOIMMUNE disease where the body mounts an immune response to GLIADIN (a product of the metabolisation of gluten)
This immune response leads to auto-destruction of villous epithelial cells - VILLOUS ATROPHY leading to decreased surface area and poor absorption
Where is the pathological change most likely to occur in coeliac disease?
Proximal small bowel
What is a common age of occurrence for coeliac disease?
There is a peak of occurrence when gluten starts to be introduced into the diet (from approx 1y) however it can present at any stage
Describe a common history for coeliac disease?
A 2 year old boy with faltered growth who was previously growing very well until the age of 12m
He is irritable and has foul smelling stools 3-4 times a day
O/E: he has slightly distended abdomen and WASTING OF THE LEG AND BUTTOCK MUSCLES
What are some presenting features of coeliac disease?
FTT or slowed or faltering growth / development Lack of energy Fatigue Wasted leg / buttock muscles Distended abdomen Flatulence and foul smelling stools Anaemia Short stature
What investigations should we do for coeliac disease?
Routine bloods: FBC + Ferritin, B12 , U&E, LFT
Autoimmune screen: Glucose, TFTs
IgA-tTG test (IgA tissue transglutaminase) - these are the antibodies that are responsible for breaking down the villous cells
- If this is only weakly positive then ENDOMYSIAL ANTOBODIES (EMAs) should also be tested for
***Test IgA levels INDEPENDENTLY AS WELL - children that are immune deficient will NOT have a raised IgA but this does not mean that they don’t have coeliac pathology
BIOPSY can be done to show villous atrophy
How should coeliac disease be managed?
Remove gluten products from diet for life
REFER TO DIETICIAN for specialist advice
Gluten challenge can be given in inconclusive cases
What is Hirschsprung’s disease?
This is an absence of ganglionic cells in the bowel
- this could be just in a small section of the bowel or it could be over a much large proportion (in 10% the whole bowel is involved)
Where in the bowel is most commonly affect by Hirschsprung’s? What affect does this have on the bowel?
The rectum - then there is varying degrees of proximal extension
The resulting bowel is narrowed and contracted
How and when does Hirschsprung’s usually present?
The baby will be unable to poo in the neonatal period and they will FAIL TO PASS MECONIUM IN THE FIRST 24 HOURS OF LIFE
- As well as failure to pass meconium there will also be some abdominal distension
- Babies can develop BILE-STAINED VOMIT but this is a late sign - should have been identified before this
What is a complication of Hirschsprung’s?
Hirscprung related ENTEROCOLITIS (due to C.diff)
How should you investigate for Hirschsprung’s?
Rectal biopsy - assess for which cells are present and for any other and-rectal abnormalities
BARIUM studies can give us an idea of how long the aganglionic area is extending
How is Hirschsprung’s treated?
The two ends of innervated bowel are anastomosed together (usually quite proximal bowel that is anastomosed to the anus) and usually the patient is provided with a colostomy (this might not be life long)
If a child presents with constipation what things should you ask?
What are they eating (ask the parent to walk you through a day)?
How much fluid are they taking?
Do they have any stomach pain?
When they do pass stool what does it look like?
Is there any blood present or pain when they are passing stool?
Are they growing normally or are there any concerns with delayed development?
Are they having any episodes of loose stool (overflow diarrhoea)
What is the most common cause of constipation in children?
Dietary causes
A common picture is a young child who is still having cow’s milk as a large part of the diet.
They are fussy, do not enjoy fruit and vegetables and fill up on milk
What are some other causes of constipation that can be serious and are important to rule out?
Hirschsprung’s
Anorectal abnormalities (think this in neonate)
Hypothyroidism (picked up in heel-prick)
Hypercalcaemia
What conservative management advice should be given to a child with constipation?
Encourage high fibre diet (fruit, veg, cereal, wholemeal options)
Encourage lots of fluids (dehydration can lead to constipation) … fluids that AREN’T MILK
Less milk
REGULAR TOILETING - suggest the child is put on the toilet for 10-15mins after every meal even if they don’t open their bowels - establish routine
Star charts
Explain how star charts work
Get a star for every time they are put on the toilet and go for a poo
Reward the positives but do not punish the negatives - they should be dealt with in a matter-of-fact way
Reward them when they get a certain number of stars - try and not give them food as a reward. Make it an activity
What factors of a child with constipation would make you consider more specific management?
If you feel the child is considerably impacted (appetite affected, having abdominal pain, have overflow diarrhoea or are taking much less food)
What more specific management can you give to children with constipation?
MOVICOL Bulking agent (moves water into stool) AND is Pro-kinetic
Other stimulant agents such as Senna can also be suggested
If these don’t work and the child is still impacted then can consider ENEMAS under GA
What is the disimpaction and maintenance regimen with movicol?
DISIMPACTION: 4 sachets on the first day and then increase by 2 sachets every day until a maximum of 12 sachets (for children <5 start at 1 sachet and increase by 2 sachets every 2 days until a max of 8 sachets)
MAINTENANCE: 2 sachets daily (max 4 sachets daily) - younger children usually fine with 1 sachet
When do symptoms of cow’s milk allergy commonly occur?
Around the time that parents start giving their child cows milk: 12 months
What are some presenting features of cow’s milk protein intolerance?
Loose stools, can be bloody
Urticarial rash - usually around the neck and face
Babies are unsettled and agitated
What can be done to investigate babies with cow’s milk protein intolerance?
They should be referred to primary care for a skin prick/specific IgE antibody test
How should cow’s milk protein intolerance be treated?
Advise the parents to avoid any lactose in the baby’s diet
Can try EXTENSIVELY HYDROLYSED FORMULAS (eHF) e.g. alimentum or aptamil pepti 1 or 2
If this doesn’t work you can try an Amino Acid Formula (AAF) and refer to secondary care
