GI/Surgery Problems Flashcards
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
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
What is Toddler diarrhoea?
Chronic diarrhoea syndrome
No other abdominal symptoms –> thriving child
Usually resolves by 5 years
What are the differentials for acute vomiting in children?
Infection:
- gastroenteritis or any other infection
- pyloric stenosis
What are the differentials for blood-stained vomiting in children?
Oesophagitis
PUD
Malrotation
Pertussis
What does bile stained vomit suggest in children?
GI obstruction
- obstruction below the sphincter of Oddi
What does chronic vomiting suggest in children?
GORD
Overfeeding
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
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
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
What is the management for effortless regurgitation after feeds?
If otherwise well –>
no intervention, improves with age, reassurance is key
What is the management for GORD in breastfed infants?
Alginate (Gaviscon) mixed with water immediately after feeds
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
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
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
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
Which conditions are associated with Coeliac disease?
T1DM AI thyroid disease Juvenile chronic arthritis Down's syndrome Turner syndrome Williams syndrome
What are the complications associated with Coeliac disease?
Osteoporosis Anaemia Short stature Delayed puberty Female infertility Intestinal malignancies (T cell lymphoma)
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
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
