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
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 (duodenum)
Dude Is (duodenum=iron) Just Feeling (jejunum=folate) Ill Bro (ilium=b12)
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?
Initial test? then what if only mildly +ve?
Definitive test?
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
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?
When they do pass stool what does it look like?(hard? amount? colour? blood?)
How often do they pass stool (2per day for 1year olds)
Are they growing normally or are there any concerns with delayed development?
Are they having any episodes of loose stool (overflow diarrhoea)
Do they have any stomach pain?
Swollen tummy?
Do they have fever?
What is the most common cause of constipation in children?
- Dietary causes most common (too much cows milk)
- 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? (4)
Hirschsprung’s (Absence of meconium within 24 hours)
Anorectal abnormalities (think this in neonate)
Hypothyroidism (picked up in heel-prick)
Hypercalcaemia
What conservative/lifestyle management advice should be given to a child with constipation?
- Encourage high fibre diet (fruit, veg, cereal, wholemeal options)
- Encourage lots of fluids (reduce dehydration)
- Less milk (high calcium can cause constipation)
- 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
- reduced appetite
- overflow diarrhoea
- adbo pain
What more specific management can you give to children with constipation?
What about if impacted?
Mild laxative regime (that can be escalated)
-1st line: MOVICOL as it is osmotic (moves water into the stool) and pro-kinetic (encourages the movement of the stool through the bowel)
2nd line: ADD Senna to the movicol if movicol alone is ineffective after 2 weeks
3rd line: If impaction is not cleared by these means then manual evacuation via ENEMAS or even UNDER ANAESTHETIC might be the only solution
If impacted give Movicol as a disimpaction dose (make sure they have access to a toilet and review in one week), then sustained on a maintenance dose)
- if movicol is not tolerated, give senna instead and add stool softener if hard (lactulose/docusate)
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?
Cows milk protein intolerance
- Vomitting after feeds (reflux)
- 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?
-reassure it resolves for most children
FORMULA FED BABIES
• extensive hydrolysed formula (eHF) milk is the first-line replacement formula for infants with mild-moderate symptoms
• amino acid-based formula (AAF) in infants with severe CMPA or if no response to eHF
• avoid soya milk
• can supplement with calcium if needed
BREAST FED BABIES
• continue breastfeeding
• eliminate cow’s milk protein from maternal diet.
• use eHF milk when breastfeeding stops
complications of gasteroenteritis
GASTEROENTERITIS
- HUS (e coli 0157) (uraemia, renal failure, thrombocytopenia)
- Guillain-Barre (campylbacteria)
- dehydration
- secondary infection (meningitis)
Investigations of gastroenteritis?
Usually none
- Baseline bloods if considerably dehydrated and needing IV fluids (FBC, U+E, CRP, glucose, CapGas to check for metabolic alkalosis)
- If severe/recent travel-stool sample/urinalysis
- Blood culture if temp high 39+
What is infantile colic?
whats the management?
Colic
- Crying for 3 hours a day, for 3 or more times a day, 3 times a week.
- reassure should get better within 6 months
Pathophysiology of food allergy vs intolerance?
Hows it tested for?
FOOD ALLERGY is IgE mediated reaction
- symptoms: atopic hx, urticarial rash, wheeze
INTOLERANCE is non immunological hypersenstivity
tested by skin testing
What is toddlers diarrhoea?
How do you manage?
Toddlers diarrhoea
- Commonly well and are growing well
- Undigested food in the diarrhoea (Peas and Carrots)
- Abdominal pain, distension, flatus, diarrhoea
- 6m-5y presentation
Management
- Reassure
- Ensure the toddler’s diet contains enough fat at this slows gut transit
How do we investigate IBD?
-It is a good idea to get a set of baseline bloods (FBC, U&E, LFT, CRP, ESR)
-Inflammatory markers are often high (CRP, ESR and platelets)
- Iron deficiency anaemia is a common
-Low SERUM ALBUMIN is another feature of IBD
- Biopsy and endoscopy
○ The presence of NON-CASEATING EPITHELIOID GRANULOMATA (crohns)
○The bowel may be narrowed, fissured or fistulad
What are the most important questions to ask in a GI history (assosiated symptoms)
- appetite
- swallowing (dysphagia)
- dyspepsia (reflux)
- pain
- nausea and vomiting
- bowels (diarrhoea/constipation/blood)
- jaundice
What is prolonged jaundice?
Prolonged jaundice
• If there are still signs of jaundice after 14 days (term) or 21 days (pre term)
How do you investigate prolonged jaundice?
Prolonged jaundice investigation
•FBC and blood film (heamolysis)
• direct antiglobulin test (Coombs’ test)
•CRP (infection)
• LFTs
• conjugated and unconjugated bilirubin:
(raised conjugated bilirubin could indicate biliary atresia > urgent surgical intervention)
• TFTs (hypothyroidism/hypopituritism
• urine for MC&S (UTI) and reducing sugars
• U&Es
•Hepatitis serology
When does breast milk jaundice resolve?
breast milk jaundice normally resolves around 6 weeks, (can take up to 4 months)
What is the transmission of hepatitis A,B,C,D,E?
Hep A-feco oral Hep B -bodily fluids/vertical Hep C -bodily fluids/vertical Hep D-bodily fluids/vertical Hep E-feco-oral
What serology would suggest Hep B infection? HBsAg/anti-HBc/anti-HBs
HBs Ag +
anti-HBc+
anti-HBs-
How much should babies be drinking?
- From 2 months babies should be feeding 150ml/kg
