GIT Flashcards
Differentiate between hematochezia vs melena
Hematochezia is fresh unaltered blood passed per rectum, May be mixed with stools
Melena is altered, partially digested blood with tarry black colour and sticks
What special investigations would you do to confirm if stool has blood
• heme (guaiac test- especially for upper GIT bleeding as globin may be denatured by gastric juice)
• antibodies to globin (immunochemical test- used to screen for distal intestinal/ colonic bleeding)
Causes of massive bleed
Portal HPT: it’s gastroesophageal varices (jaundice, ascites, abdo wall varices, hepatomegaly, petechia/purpura/ecchymoses from lower platelet count in hypersplenism, spider naevi, clubbing) Abdo US to confirm
Meckels diverticulum with ectopic gastric mucosa causing intestinal ulceration typically ~18 months to 5 years of age with painless bright red
blood/ maroon blood and no other signs
• Epistaxis (easily swallow +- vomit blood after major nosebleed)
• Pulmonary haemorrhage: risk factors & signs/ symptoms of tuberculosis
• Gastritis/ peptic ulcer in hospitalized patients especially ICU/burns/ on non-
steroidal anti-inflammatory
• Peutz-Jeghers (oral mucosal freckling; axillary freckling in older children)-
bleeding from hamartomatous polyps
• Hereditary Haemorrhagic Telangiectasia (possible family history)-
mucocutaneous lesions may be present; consider abdominal ultrasound to
look for large solid organ arteriovenous malformations but elective upper and lower GIT endoscopy after bowel preparation may be needed to detect GIT
lesions
• Amoebic colitis: Infection (high grade fever) & acute abdomen (generalized
peritonitis) present?» urgent surgery together with high-dose metronidazole
(15mg/kg); fresh stool sample for ova/ histology
Possible causes of chronic slow or recurrent bleed
Physiological adaptation to Hb<6 , don’t transfuse if haemodynamically stable
Parasite infection
Haemangiomas
Intestinal polyps
Gastritis (peptic ulcer uncommon)
What are the most common causes of abdominal pain in paeds inorder of frequency
(NGCUVAS)
1. Non-specific abdominal pain (unknown cause)
2. Gastroenteritis
3. Constipation
4. Urinary tract infection: always check urine dipstick
5. Viral infection
6. Appendicitis: (~1% of general practitioner visits for abdominal pain)
7. Streptococcus Pharyngitis
8. Pharyngitis
9. Pneumonia
10. Otitis Media
Outline the Rome criteria that can be used to conform functional constipation (6)
• 2 or less stools per week
• 1 or more episodes of incontinence per week (after toilet training)
• History of excessive stool retention (trying to avoid passing stools)
• History of hard or painful bowel movements
• Presence of large faeculoma in the rectum (clinically or on X-Ray)
• History of passing large diameter stools (may even obstruct the toilet)
Indications for workup for possible Hirschsprung’s disease (5)
o Delayed passage of meconium (>48 hours in term infants)
o Constipation since first few weeks of life
o Chronic abdominal distension plus vomiting
o Family history of Hirschsprung’s disease
o Faltering growth in addition to any of the above
Causes of constipation
• Cerebral palsy or other central nervous system abnormalities
• Inherited and genetic abnormalities (Trisomy 21, cystic fibrosis, etc)
• Spinal defects (myelomengingocele, tethered cord, sacral agenesis, previous
pelvic or spinal surgery, traumatic spinal cord injury, etc)
• Autism
• Hypothyroidism
• Any anorectal disorder (imperforate anus, Hirschsprung’s disease)
Diet
Meds (opiates, antidepressants)
Red flags for constipation (where you need to refer for further investigation)
• Delayed passage of meconium, or constipation from the first weeks of life
• A family history of Hirschsprung’s disease
• Recurrent urinary tract infections (fistula/incontinence??)
• A history of soiling
• An acutely ill child with vomiting, abdominal distension, peritonism,
dehydration or evidence of sepsis
• Chronic abdominal distension with episodes of vomiting
• A child with malnutrition or failure to thrive
• Any evidence of an occult spinal defect
• Any evidence of an anorectal malformation
Management of constipation
Acute treatment
1. Empty colon: phosphate enema 2-3 days
-inpatients polyethylene glycol orally or via NGT at 10-30ml/kg/hr 6-8 hrs, repeat if necessary
-manual disimpaction of above fails
Maintainance
1. Diet advice
2. Behaviours modification: adequate stooling time 20-30min everyday, after breakfast
3. Stool softener orStimulant laxative in children <2 ie Lactulose + Senekot with bisacodyl
Indications for surgery in a paeds patient with GERD
• Inability to tolerate bolus oral or nasogastric feeds with failure to thrive
• Apnoea spells
• Recurrent lower tract infections
• Oesophageal stricture
Causes of intessusception
Idiopathic
-following gastrointeritis or a Resp infection
Meckels diverticulum
Following surgery (retroperitoneal surgery)
Symptoms of intessusception
• Sudden onset of colicky abdominal pain associated with vomiting.
• Pain is severe enough to wake the child. The classic feature is one of pulling the
legs up to the abdomen during the pain. The pain is colicky and intermittent and
may then go away only to return every half hour or so, lasting 20 to 30 seconds.
The child lies very still in between attacks.
• Vomiting may initially be milk feeds but becomes bilious, and later faeculent
• Passage of blood and mucus per rectum (“RED CURRANT JELLY” stools)
• Progressive abdominal distension.
How to Dx intessusception
- Abdo US
- Contrast enema
Can also do AXR after?
Management of intessusception
Initial stabilisation (IV fluids, NGT, IVAb, IV analgesia)
Non operative reduction
Surgical reduction
Indications for surgery
- successful non- operative reduction
- peritonitis
- a proven lead point intussusception or that in an older child above age 2
-small bowel intussusception
Investigations in GI bleed
Upper GI- gastroduodenectomy
Lower- colonoscopy
Distension in neonates and blood PR- Xray to dx NEC
Clinical presentation of ingested foreign bodies
Ingestion
-dysphasia
-drooling
-spitting
-vomiting
-airway compression from behind
Aspiration
-Coughing and gagging
-May have no sx
-Breathlessness
-Wheeze
-Stridor
-Acute Aphonia
-Recurrent Pneumonias
Acute: coughing, gagging, choking,
Chronic: poor feeding, drooling, wheeze, cough, haematemesis, recurrent pneumonias, lung abscess
Main investigation in malrotation
Contrast meal
Causes of malrotation
Congenital diaphragmatic hernia
Exomphalos
Gastroschisis
Situs inversus
Management of Volvulus
• Nasogastric tube decompression
• Resuscitation with intravenous fluid & correction of metabolic derangement. This
should not delay transfer to definitive care. Ongoing fluid resuscitation on the
operative table may be necessary
• If a diagnosis of midgut volvulus is confirmed on contrast meal and follow-
through, immediate surgical management is essential
. Laparotomy and derogation of bowel as emergency surgery
how long can bowel necrosis occur following volvulus
Within 6hours of cutoff blood supply
What causes paradoxical aciduria in hypertrophic pyloric stenosis
Low serum potassium is present during severe dehydration due to intracellular
movement of the potassium. Potassium is also preferentially retained in the
kidneys via the K+/H+ pump at the expense of losing hydrogen in the urine, even
though the patient is already alkalotic (paradoxical aciduria)
Management of hypertrophic pyloric stenosis
Nasogastric tube
Intravenous fluid therapy:
• Fluid boluses of normal saline may be required to correct initial dehydration. A
urine output of 1 ml/kg/hour should be achieved.
• Maintenance fluid and electrolyte replacement (“half normal saline” 0.45%NaCl,
with KCl and5% dextrose added at 130-150% of normal maintenance fluid
infusion rate i.e. 180-220ml/kg/day) is then started.
• There is a risk of pontine demyelination if the sodium is raised too quickly, so
regular blood sodium monitoring is important in these patients, especially is
normal saline is being administered
What causes NEC and what are some of the risk factors
Inflammatory response in response to pathogenic gut bacteria due to an immature immune system.
Common in prematurity as the immune system is still immature.
Lack of protective factors from human breast milk exposure (remember breastmilk enhances their immune system)
Risk factors
-diabetic mother
-chorioamnionitis
-maternal HIV
-maternal use of drugs
-HIE
-Blood transfusion
-lack of breast milk
-pathogenic bacteria in neonatal ICU (prem baby)
DDx for NEC
Spontaneous intestinal perforation
Bowel obstruction (volvulus, incarcerated inguinal hernia)
GORD
Differentiate pneumoperitonium and pneumotosis intestinalis
Pneumotosis intestinalis is presence of gas within the wall of the small or large intestine.
Pneumoperitoneum is presence of gas in peritoneum/abdominal cavity, usually seem on xray
Clinical presentation of NEC
Infectious, Hypoxic or metabolic insult
Signs of sepsis (pyrexia, glucose instability, apnoea)
Bloody stool/vomitus
Tender abdo
Distension, palpable bowel loops
Acidosis, hyperkalemia, erythema and blue black discolouration
When do you surgically operate on NEC
Stage 3B: severe NEC with perforation
Many 3As are also operated on (severe NEC with organ dysfunction)
