GI, Vomiting, Malabsorption, Lower GI disorders, Paediatric Liver Disease Flashcards
What are some signs and symptoms of constipation?
Poor appetite Irritable Lack of energy Abdominal pain or distension Withholding or straining
Why do children become constipated?
Social (poor diet, insufficient fluids, excessive milk, potty training / school toilet)
Physical (intercurrent illness, medication)
Family history
Psychological (secondary)
Organic
How can constipation be treated with diet?
Increase fibre
Increase fruit and vegetables
Increase fluids
Decrease milk
How can constipation be treated psychologically?
Make going to toilet a good experience (correct height, not cold, school toilets)
Avoid punitive behaviour from parents
What treatments can soften stool and stimulate defecation?
Osmotic laxatives (lactulose) Stimulant laxatives (senna, picolax) Isotonic laxatives (movicol)
What are the advantages of laxatives?
Non invasive
Given by parents
What are the disadvantages of laxatives?
Non compliance
Side effects
What is the treatment for impaction?
Empty impacted rectum
Empty colon
Maintain regular stool passage
Slow weaning off treatment
What are the presenting features for Crohn’s ad ulcerative colitis?
Diarrhoea Rectal bleeding Abdominal pain Fever Weight loss Growth failure Arthritis Mass
What lab investigations are used in crohn’s and ulcerative colitis?
FBC and ESR (anaemia, thrombocytosis, raised ESR)
Biochemistry (stool calprotectin, raised CRP, low albumin)
What other investigations can be used for Crohn’s and ulcerative colitis?
MRI Barium meal Colonoscopy Upper GI endoscopy Mucosal biopsy Capsule endoscopy Enteroscopy
What are the methods of treatment for Crohn’s and ulcerative colitis?
Medical (anti-inflammatory, immunosuppressive, biologics)
Nutritional (immune modulation, supplements)
Surgical
What are the different types of vomiting?
Vomiting with Retching
Projectile vomiting
Bilious vomiting
Effortless vomiting
What are the different phases of vomiting with retching?
Pre-ejection phase (pallor, nausea, tachycardia)
Ejection phase (retch, vomit)
Post-ejection phase
What can stimulate the vomiting centre?
Enteric pathogens Intestinal inflammation Metabolic derangement Infection Head injury Visual stimuli Middle ear stimuli
What are the symptoms of pyloric stenosis?
Projectile non-bilious vomiting
Weight loss
Dehydration +/- shock
Electrolyte disturbance (Metabolic alkalosis ↑pH, ↓Cl, ↓K)
What type of vomiting is associated with gastroesophageal reflux?
Effortless vomiting
What are the presenting symptoms for gastroesophageal reflux?
Vomiting Haematemesis Feeding problems Failure to thrive Apnoea Cough Wheeze Chest infections
What are the investigations for pyloric stenosis?
Test feed
US
Blood gases
What is the management for pyloric stenosis?
Fluid resuscitation
Refer to surgeons (Ramstedts pyloroyotomy)
What investigations are used for gastroesophageal reflux?
Barium swallow Video fluoroscopy pH study Oesophageal impendance monitoring Endoscopy
What is the treatment for gastroesophageal reflux?
Feeding advice
Nutritional support (calorie supplements, exclusion diet, NG tube, gastrostomy)
Drugs (feed thickener, pro kinetic drugs, H2 receptor blockers, PPI)
Surgery
What are the indications for gastroesophageal reflux surgery?
Failure of medical treatment
Persistent failure to thrive, aspiration and oesophagiitis
What are the causes of bilious vomiting?
Intestinal atresia (in newborn babies only) Malrotation +/- volvulus Intussusception Ileus Crohn’s disease with strictures
What are the investigations for bilious vomiting?
Abdominal x-ray
Consider contrast meal
Surgical opinion re exploratory laparotomy
What is chronic diarrhoea?
4 or more stools per day more than 4 weeks
What are the causes of diarrhoea?
Motility disturbance (Toddler Diarrhoea, Irritable Bowel Syndrome) Active secretion (Acute Infective Diarrhoea, Inflammatory Bowel Disease) Malabsorption of nutrients (Food Allergy, Coeliac Disease, Cystic Fibrosis)
What is osmotic diarrhoea?
Movement of water into the bowel to equilibrate osmotic gradient
What can cause fat malabsorption?
Pancreatic disease (cystic fibrosis) Hepatobiliary disease (chronic liver disease, cholestasis)
What is secretary diarrhoea?
Associated with toxin production from E coli
Intestinal fluid secretion is driven by active CL secretion via CFTR
What are the causes of motility diarrhoea?
Irritabel bowel syndrome
Congenital hyperthyroidism
What is inflammatory diarrhoea?
Malabsorption due to intestinal damage
Secretory effect of cytokines
Accelerated transit time in response to inflammation
Protein exudate across inflamed epithelium
What are the investigations for diarrhoea?
History
Consider growth and weight gain of child
Faeces analysis
What are the signs of coeliac disease in children?
Abdominal bloatedness Diarrhoea Failure to thrive Short stature Constipation Tiredness Dermatitis herpatiformis
Who are the susceptible asymptomatic groups for coeliac disease?
Type 1 diabetes
Autoimmune thyroid disease
Down’s syndrome
First-degree relatives of people with coeliac disease
What are the screening tests for coeliac disease?
Serology screens (anti-tissue transglutaminase, anti-endomysial, concurrent IgA deficiency)
Duodenal biopsy
Genetic testing
What are the histological features of coeliac disease?
Villous atrophy
Crypt hyperplasia
Lymphocytic infiltration of surface epithelium
What is the treatment for coeliac disease?
Strict gluten free diet
What is the risk of azathioprine?
Lymphoma risk
What are the advantages of breast milk?
Well tolerated Less allergenic Low renal solute load Improves cognitive development Reduces infection
What is included in liver function tests?
Bilirubin
ALT/AST
Alkaline phosphatase
Gamma glutamyl transferase (GGT)
What liver function tests will be elevated in biliary disease?
Alkaline phosphatase
GGT
What liver function tests will be elevated in hepatocellular damage?
ALT/AST
What are some other tests which can assess liver function?
Coagulation (prothrombin time) Albumin Bilirubin Blood glucose Ammonia
What are the signs of chronic liver disease in children?
Ascites Portal hypertension Clubbing Splenomegaly Cholestasis Brusing and petechiae Spider neavi Muscle wasting Jaundice Hypotonia Growth failure
What are the early causes of neonatal jaundice?
Haemolysis
Sepsis
What are the intermediate causes of neonatal jaundice?
Breast milk
Sepsis
Haemolysis
What are the prolonged causes of neonatal jaundice?
Extrahepatic obstruction
Neonatal hepatitis
Hypothyroidism
Breast milk
What are the features of physiological jaundice?
Shorter RBC lifespan in infants Relative polycythaemia Relative immaturity of liver function Unconjugated jaundice Develops after first day of life
What are the features of great milk jaundice?
Unconjugated jaundice
Can persist up to 12 weeks
What is kernicterus?
Unconjugated bilirubin is fat soluble and crosses the BBB
Neurotoxic and deposits in the brain
What are the early signs of kernicterus?
Encephalopathy
Poor feeding
Lethargy
Seizures
What are the consequences of kernicterus?
Severe choreoathetoid cerebral palsy
Learning difficulties
Sensorineural deafness
What type of jaundice can phototherapy treatment be used?
Unconjugated jaundice
What types of biliary obstruction can cause prolonged neonatal jaundice?
Biliary atresia (Conjugated jaundice, pale stools) Choledochal cyst (Conjugated jaundice, pale stools) Alagille syndrome (Intrahepatic cholestasis, dysmorphism, congenital cardiac disease)
What is the treatment for biliary atresia?
Kasai portoenterostomy
