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
When do babes normally get GORD/when will it resolve?
Why is reflux more common in babies?
GORD
Babies normally get it before 2 months-should resolve around 1 year
- They have poor tone in their spincter
- 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? (8)
GORD
- Over-feeding - probably the most common cause (parents worried baby isn’t keeping down feeds- makes it worse)
- Hiatus hernia
- Pre-term
- Hypotonic (for whatever reason e.g. Down Syndrome)
- Sandifers
- Male sex
- Cow’s Milk allergy
What are some complications of GORD?
GORD
- Oesophageal stricture
- Barret’s oesophagus
- Faltering growth
- Anaemia
- Lower respiratory disease (aspiration)
How does GORD commonly present?
GORD
- Vomiting and regurgitation following feeding (non billious)
- Reduced feeding
- Irritation/crying
- Weight loss or failure to gain weight
- 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 If failure to thrive: -PH study-stays in nose for 24 hours -FBC (anemia/pnuemonia) -Us and Es -LFTs
How should GORD be managed?
GORD management
REASSURE
-usually will self resolve by 1 year (weaning children will really help)
LIFESTYLE
- Positioning: really important to feed at 30 degrees and keep upright after feeds
- Feeding: smaller but more frequent. Not before bed
BOTTLE FED
- Thickened feeds (CAROBEL)
BREAST FED
- Gaviscon infant trial for 2 weeks with follow up
- If doesn’t work try Ranitidine (H2) or PPI
What is a potential risk of PPIs in babies?
Small risk of NEC in babies so try and avoid if possible
What is gastroenteritis? (definition)
What is the most common causative agent for gastroenteritis in developed countries?
What are some other less common causes?
Gastroenteritis
- >3 watery stools in 24 hours - With or without vomiting - It will normally last around 1 week, but not longer than 2 weeks
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 (can lead to Guillain-Barre)
Shigella and salmonella
E.coli (can lead to HUS) (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?
SOCRATES
Any blood or mucus?
Can you describe what the stool/vomitlooks 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 (should be non bilious) , rashes?
Has the child been eating and drinking and how much?
What would be some indications for admission in children with gastroenteritis? (think about how many vomits/poos in a day)
SIGNSof dehydration (sunken fontanelle, high central cap refill, sunken features, unwell looking baby, pale, tachycardic, tachypnoea) or RISK FACTORS for dehydration:
Poor feeding (<50-75%) Young age (<6m) Small birth weight >6 stools in 24h >3 vomitting episodes in 24h
Management of Gastroenteritis?
If they have signs of dehydration from gastroenteritis Mild dehydration - Give oral fluids - Oral rehydration salts - Admit if worsening
Moderate dehydration - Encourage oral fluids ○ IV fluids/ NG tube if not - Oral rehydration salts - Admit if worsening
Severe dehydration
- ABCDEG assessment regularly
- Admit and assess regularly
How do we assess the child for clinical signs of dehydration?
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
- isotonic solution (0.9% saline)
- calculate well and look at max dose (cerebral oedema)
- otherwise they will risk becoming hypotonic (can result in convulsions)
How would you prescribe fluids for a child who was dehydrated?
Work out amount for child weighing 32kg?
Fluids for dehydrated children
- BOLUS of 20mls/kg if shocked (10ml/kg if not)
- CORRECT DEFICIT
- MAINTAINANCE
DEFICIT
% dehydration x weight x 10 = deficit in mls
Mild - 1-5% body weight loss
moderate: 6-10%
severe: over 10% weight loss
MAINTANANCE (24hours)
o 0-10kg 100ml/kg/day
o 10-20kg 1000ml+50ml/kg for each kg above 10
o 20+kg 1500+20ml/kg for each kg above 20
E.g. A 32kg child that is 5% dehydrated works out like
10kg @ 100mls = 1000mls
10kg @ 50mls = 500mls
12kg @ 20mls = 240mls so 24hr maint=1740ml
deficit
(5) x 32 x 10ml = 1600ml
SO total fluid required = 1740ml + 1600ml =3340ml
Management of gastroenteritis?
Management of gastroenteritis -Rehydration therapy is the main objective (oral, NGT or IV) -Zinc supplementation -Consider oral rehydration salts e.g. dioralyte -Education (hand washing, keep eating) -Abx only given if: ○ Suspected or confirmed sepsis ○ Salmonella under the age of 6/12 ○ For specific infections such as C.dif
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
-Rehydrate and reassure-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? (colour?food?blood?)
-green (bilious)? - CONCERNING
-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/what?
Are they taking any fluids at all/how much?
Any rashes?
Does the child have a sore swollen stomach (examination)
What are some common causes of vomiting in children?
reflux / GORD
Feeding problems / over-feeding
DKA
Gastroenteritis
Other infections incl. URTI/OM/ Whooping cough/sepsis
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
