GI/Surgery Problems Flashcards by Megan Rose

What is the differential for non-bloody diarrhoea in children?

Infectious: gastroenteritis or any infection (UTI, appendicitis)
Malabsorption: CF, Coeliac (also causes constipation)
Dietary: cow’s milk protein allergy, lactose intolerance
IBD
IBS

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What is the differential for bloody diarrhoea in children?

Infectious + inflammatory:
- bacterial GE, IBD, NEC, HUS
Obstruction:
- intussusception, midgut volvulus
Cow’s milk protein allergy (flecks of blood)
Juvenile polyps or Meckel’s may cause PR bleeding without diarrhoea

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What is Toddler diarrhoea?

Chronic diarrhoea syndrome
No other abdominal symptoms –> thriving child
Usually resolves by 5 years

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What are the differentials for acute vomiting in children?

Infection:

gastroenteritis or any other infection
pyloric stenosis

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What are the differentials for blood-stained vomiting in children?

Oesophagitis
PUD
Malrotation
Pertussis

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What does bile stained vomit suggest in children?

GI obstruction

- obstruction below the sphincter of Oddi

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What does chronic vomiting suggest in children?

GORD

Overfeeding

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What are the risk factors for GORD in children?

Prematurity
Parental history of heartburn or reflux
Obesity
Hiatus hernia
Repaired congenital diaphragmatic hernia
Repaired congenital oesophageal atresia
Neurodisability e.g. cerebral palsy

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What is the difference between GOR + GORD?

Gastro-oesophageal reflux is normal in infants if asymptomatic

GORD is the presence of symptoms/complications from the reflux

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What are the symptoms of GORD in infants?

Distressed behaviours e.g. excessive crying, unusual neck postures, back arching
Unexplained feeding difficulties e.g. refusing, gagging, choking
Hoarseness +/- chronic cough
Episode of pneumonia
Faltering growth

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What is the management for effortless regurgitation after feeds?

If otherwise well –>

no intervention, improves with age, reassurance is key

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What is the management for GORD in breastfed infants?

Alginate (Gaviscon) mixed with water immediately after feeds

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What is the management for GORD in formula-fed infants?

Ensure infant not over-fed (no more than 150ml/kg/day)
Decrease feed volume by increasing frequency
Use feed thickener if still no better
Stop thickener and start alginate added to formula

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If there is no improvement following alginate therapy for two weeks, what should be done next for an infant with GORD?

Try ranitidine

or omeprazole

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When should serological testing for Coeliac disease be offered to children?

Persistent, unexplained GI symptoms
Faltering growth
Prolonged fatigue
Unexpected weight loss
Severe or persistent mouth ulcers
Unexplained iron, B12 or folate deficiency
T1DM or AI thyroid disease at diagnosis

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How is Coeliac disease diagnosed?

Patient must have gluten in diet for at least 6 weeks before test

Test for total IgA + IgA tissue transglutaminase (tTG)

If serology positive –> duodenal biopsy:

lymphocytic infiltration
crypt hyperplasia +/- villous atrophy
biopsy sometimes not necessary in children if classic symptoms + tTG > 10x upper limit of normal

Second sample for:

anti-endomesial antibodies (EMA)
HLA DQ2 + DQ8 phenotyping

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Which conditions are associated with Coeliac disease?

T1DM
AI thyroid disease
Juvenile chronic arthritis
Down's syndrome
Turner syndrome
Williams syndrome

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What are the complications associated with Coeliac disease?

Osteoporosis
Anaemia
Short stature
Delayed puberty
Female infertility
Intestinal malignancies (T cell lymphoma)

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How is constipation diagnosed in children?

At least 2 of the following, present for at least 1 month:

< 3 bowel movements per week
faecal incontinence at least once per week (after toilet trained)
excessive stool retention or retentive posturing
painful or hard bowel movements
large faecal mass in rectum
large diameter stools

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Which features of constipation may be suggestive of a organic cause?

Delayed passage of meconium >24 hours
Recurrent rectal prolapse (CF)
Failure to thrive
Abnormal position of anus
Explosive passing of stools following rectal exam (Hirschsprung’s)
Skin tags - usually caused by healed fissures (Crohn’s, sexual abuse)

How is constipation treated in children?

Softeners e.g. laxido
Monitor with Bristol stool chart
May need to add stimulant e.g. Docusate or Senna

What are the features of GI obstruction in children?

Vomiting, may be bile stained if obstruction below the sphincter of Oddi
Abdominal distension, esp if lower

What are the possible causes of GI obstruction in children?

Pyloric stenosis
Duodenal atresia (first 24 hours of life)
Intussusception
Malrotation + volvulus
Meckel's diverticulum
Strangulated inguinal hernia
Hirschsprung's
Meconium ileus

What is intussusception and when does it usually present?

Telescoping of the bowel, usually of ileum into caecum

Usually age 6-36 months

What are the clinical features of intussusception?

Episodic, severe colicky pain + pallor, with knees drawn up Sausage shaped mass in abdomen +/- distension Redcurrent jelly stool (blood stained) - late sign, suggests ischaemia has occurred Bile-stained vomit Shock

How is intussusception diagnosed?

USS --> doughnut sign

How is intussusception managed?

US guided air enema insufflation | Surgery needed in 25%

What is Hirschsprung's disease?

Congenital absence of ganglion cells in mesenteric + submucosal plexus Absence of parasympathetic action --> bowel obstruction 10% also have Down's

What are the clinical features of Hirschsprung's?

Delayed passage of meconium > 48 hours Abdominal distension Chronic constipation + overflow diarrhoea Vomiting, may be bilious Enterocolitis is a serious complication (explosive diarrhoea + sepsis)

How is Hirschsprung's diagnosed?

Rectal biopsy --> absence of ganglion cells | Barium enema shows dilated proximal colon + contracted distal colon

What is malrotation + volvulus?

Malrotations are congenital anatomical abnormalities of the GI tract Volvulus is a severe complication of this --> loop of bowel twists around mesenteric attachment --> obstruction

Where are when does malrotation volvulus most commonly occur?

Midgut volvulus --> twisting around SMA (superior mesenteric artery) < 1 year old

What are the clinical features of malrotation volvulus?

Bilious (green) vomit Severe, acute abdominal pain Abdominal distension Systemic symptoms if there is ischaemia

Which investigation is done for malrotation volvulus and what does it show?

Upper GI contrast study, with contrast through NG tube or bottle --> corkscrew duodenum

How is malrotation (without volvulus) managed?

Elective surgery --> Ladd's procedure to untwist bowel

How is volvulus managed?

Drip + suck --> IV fluids + NG decompression | Followed by urgent surgery

What are the clinical features of pyloric stenosis?

Presents at 2-7 weeks with: - projectile, non-bilious vomiting after feeds - hunger - olive shaped mass in RUQ - visible peristalsis

How is pyloric stenosis managed?

Fluids | Surgical repair --> pylorotomy (splitting pyloric muscle)

What is mesenteric adenitis and how does it present?

Mesenteric lymph node enlargement, associated with URTI or other viral infection - generalised abdominal pain - main differential of appendicitis in children - may have headache + photophobia

Which FBC feature would be present in mesenteric adenitis?

``` Raised lymphocytes (neutrophils would be raised in appendicitis) ```

How is mesenteric adenitis managed?

Simple analgesia

What is cow's milk protein allergy?

Allergic reaction to casein or whey proteins in milk (not lactose) Can be IgE mediated (type 1 hypersensitivity) or non-IgE mediated (type 4)

What are the risk factors for cow's milk protein allergy?

Family history of atopy | Breast feeding increases risk of non-IgE mediated but reduces risk of IgE mediated

What are the features of IgE mediated cow's milk protein allergy?

Immediate urticaria + face swelling | If severe: diarrhoea, vomiting + anaphylaxis

What are the features of non-IgE mediated cow's milk protein allergy?

Failure to thrive + poor feeding Loose stools, may contain streaks of blood Abdominal pain Vomiting, possible with blood May be treatment resistant GORD, eczema or colic

How is cow's milk protein allergy diagnosed?

Usually clinically based on good history + examination Blood test for specific IgE to cow's milk protein (RAST testing) can be useful for IgE mediated allergy if unclear

How is cow's milk protein allergy managed?

Avoidance of cow's milk in all forms, including mother's diet if breast feeding If formula fed replace with hypoallergenic formula: - extensively hydrolysed formula (made from cow's milk but proteins broken down) - amino acid formula (second line) Re-evaluate every 6-12 months to assess tolerance to cow's milk protein

Can soya milk be used in cow's milk protein allergy?

Not recommended due to oestrogenic effect