GI Paeds Flashcards
Is constipation common?
Yes
What is constipation?
Infrequent passing of stool
What should be asked about constipation?
How often
How hard
Painful?
Change in habit?
What are other signs or symptoms of constipation?
Poor apetite Irritable Lack of energy Abdominal pain or distension Withholding or straining Diarrhoea
Why can children get constipated?
Poor diet - insufficient fluids or excessive milk
Stress about potty training or school toilet
Physical - intercurrent
illness/medication
Family history
Psychological - secondary constipation
Organic - anorectal malformation, hypothyroid
What is the vicious cycle of constipation?
Withholding of stool leads to constipation, which leads to large hard stool, which leads to pain or anal fissure, which leads to withholding of stool
What dietary changes can help with constipation?
Increased fibre
Increased fruit and veg
Increased fluids
Decreased milk
What is the most important social factor of management?
Explain treatment to patients
What are psychological factors in treatment of constipation?
Reduce aversive factors - make toilet a pleasant experience - correct height, not cold, fuck school toilets
Soften stool and remove pain
Avoid punitive behaviour from parents
Reward good behaviour - general praise and and star charts
What can be done to soften stool and stimulate defecation?
Osmotic laxatives
Stimulant laxatives
Isotonic laxatives
What is an example of an osmotic laxative?
Lactulose
Movicol
Laxido
What are examples of stimulant laxatives?
Senna
Picolax
What do stimulant laxatives do?
Aggravate/irritate the desensitised colon
What are presenting features of Crohn’s in children?
May have diarrhoea May have rectal bleeding Abdominal pain is common Fever is uncommon Weight loss very common Growth failure very common May lead to arthritis May have a mass
Is it common for children with ulcerative colitis to have a pancolitis?
Yes
What is the most common crohn’s presentation?
Panenteric disease
What are common features of UC in children?
Diarrhoea and rectal bleeding extremely common
May have abdominal pain
Weight loss and growth failure unlikely
May develop arthritis
What determines Crohn’s symptoms?
Location of disease
What are you looking for in history and examination of children with IBD?
Intestinal symptoms Extra-intestinal manifestations ie arthritis, uveitis, erythema nodosum Exclude infection Family history Growth and sexual development Nutritional status
What lab investigations should be done for IBD?
FBC and ESR
Biochemistry
Microbiology
What biochemistry tests should be done for IBD?
Stool calprotectin
Raised CRP
Low albumin
What should be assessed in FBC?
Anaemia
Thrombocytosis
Raised ESR
What are definitive investiagyions for IBD?
Radiology - MRI, barium meal Colonoscopy Upper GI endoscopy Enteroscopy Capsule endoscopy Mucosal biopsy gold standard
What medications can be used for IBD?
Anti-inflammatory medicines
Immuno-suppressive
Biologicals (infliximab)
What are the 3 broad treatment groups for IBD?
Medical
Nutritional
Surgical
What is fecal impaction?
Stool accumulates in the rectum to the point that the body can’t remove it
How is fetal impaction generally treated?
Empty impacted rectum
Empty colon
Maintain regular stool passage
Slow weaning off treatment
How is fetal impaction generally treated?
Empty impacted rectum
Empty colon
Maintain regular stool passage
Slow weaning off treatment
What do the different types of stool from the bristol stool chart indicate?
Type I - Very constipated Type II - Slightly constipated Type III+IV - Normal Type V - Lacking fibre Type VI+VII - Inflammation
What are the different types of child vomiting?
Vomiting with retching
Projectile vomiting
Bilious vomiting
Effortless vomiting
What are features of pre-ejection phase in vomiting with retching?
Pallor
Nausea
Tachycardia
What are features of post-ejection phase of vomiting with retching?
Weakness
Shivering
Lethargy
What can cause stimulation of vomiting centre?
Enteric pathogens Intestinal inflammation Metabolic derangement Infection Head injury Visual stimuli Middle ear stimuli
What are features of pyloric stenosis on test feed?
Palpation of olive tumour
Visible gastric peristalsis
Projectile NON BILIOUS vomiting
What are blood gas features ofpyloric stenosis?
Raised pH - metabolic alkalosis due to vomiting stomach acid
Hypochloraemia
Hypokalaemia
What is medical management for pyloric stenosis?
Fluid resuscitation - correct electrolyte imbalance and alkalosis
Refer to surgeons
What surgical procedure is done for pyloric stenosis?
Ramstedts pyloromyotomy
What colour is bilious vomit?
Green
What causes bilious vomiting?
Intestinal obstruction - green vomit is obstruction until proven otherwise
What conditions cause bilious vomiting?
Intestinal atresia in newborn babies Malrotation Intussusception Ileus Crohn's disease with strictures
What investigations are done into bilious vomit?
Abdo X-ray
Contrast meal
Exploratory laparotomy
What causes effortless vomiting?
Gastro-oesophageal reflux
Is gasto-oesophageal reflux self limiting?
Normally yes - resolves spontaneously
When is reflux not self limiting?
Cerebral palsy
Progressive neurological problems
Oesophageal atresia
Generalised GI motility problem
What are presenting symptoms of reflux?
Vomiting Haematemasis Feeding problems Failure to thrive Resp - Apnoea, cough, wheeze, chest infections
How is reflux assessed?
History and examination Radiology - video fluoroscopy, barium swallow pH study Oesophageal imedance monitoring Endoscopy
What are aims for barium swallow?
Identify: Dysmotility Hiatus hernia Reflux Gastric emptying Strictures
How is a pH meter used?
pH catheter inserted into oesophagus with sensor to detect pH
How is reflux generally managed?
Feeding advice
Nutritional support
Medical treatment
Surgery
What is involved in feeding advice for reflux?
Thickeners for liquids
Appropriateness of foods - texture and amount
Behavioural programme - oral stimulation and removal of aversive stimuli
Feeding position
What is involved in nutritional support for reflux?
Calorie supplements
Exclusion diet - milk free (may have cow’s milk allergy)
Nasogastric tube
Gastrostomy
What is involved in medical treatment of reflux?
Feed thickener - gaviscon, thick and easy
Prokinetic drugs
Acid supressing drugs - H2 receptor blockers, PPIs
What are indications for surgery in reflux?
Failure of medical treatment - persistet failure to thrive, aspiration, and oesophagitis
What surgery is done for reflux?
Nissen funcoplication
What are complications of nissen fundoplication?
Dumping syndrome
Bloating
Retching
More problematic with neuro pathology
How is chronic diarrhoea defined?
4 or more stools per day for more than 4 weeks
What is diarrhoea lasting less than one week?
Acute diarrheoa
What is diarrhoea that lasts 2-4 weeks?
Persistent diarrhoea
What are the 3 main causes of diarrhoea?
Motility disturbance
Active secretion - secretory diarrhoea
Malabsorption of nutrients - osmotic diarrhoea
What types of diarrhoea are caused by motility disturbance?
Toddler diarrhoea
Irritable bowel syndrome
What types of diarrhoea are caused by active secretion?
Acute infective diarrhoea
IBD
What types of diarrhoea are caused by osmotic diarrhoea?
Food allergy
Coeliac disease
CF
What is the most common cause of secretory diarrhoea?
Cholera
What is used to treat secretory diarrhoea?
Oral rehydration therapy
What causes osmotic diarrhoea?
Food that is not absorbed remains in lumen and pulls water out of cells into lumen through osmosis
What should be asked about in history of chronic diarrhoea?
Age at onset
Abrupt or gradual onset
Family history
Nocturnal defecation 0 organic pathology
What should be done in faecal analysis in chronic diarrhoea?
Appearance
Stool culture
Determination of secretory vs osmotic
Stop feed to determine osmotic or secretory - will stop if osmotic
What are differences in lab results between osmotic and secretory diarrhoea?
Osmotic has lower volume
Osmotic stops in response to feeding
Osmotic has high stool osmolality
What can cause fat malabsorption?
Pancreatic disease - lack of lipase, classically CF
Hepatobiliary disease - cholestasis
What is coeliac disease?
Gluten sensitive enteropathy
What are features of coeliac disease?
Abdominal bloatedness Diarrhoea Failure to thrive Short stature Constipation Tiredness Dermatitis herpatiformis
What are screening tests for coeliac disease?
Serum Anti-tissue transglutaminase Serum Anti endomysial Serum IgA Duodenal biopsy - gold standard Genetic testing
How is coeliac disease treated?
Gluten-free diet for life
Gluten must not be removed prior to diagnosis as serological and histological features will resolve
In very young <2yrs, re-challenge and re-biopsy may be warranted
Increased risk of rare small bowel lymphoma if untreated
When can coeliac be treated without biopsy?
Symptomatic
Anti tissue transglutaminase >10 times upper limit
Positive anti endomysial antibodies
Positive in genetic testing
What are complications of untreated coeliac disease?
Growth failure
Osteoperosis
Small bowel lymphomas
