ILA- gastro and renal

Question 1

A four month old boy is referred to the outpatient clinic because of concerns about his weight gain. At birth he was on the 25th centile for weight, with his head circumference on the 50th. Since two months of age his weight gain has slowed and his weight is now below the 0.4th centile. His head circumference remains on the 50th centile. The baby is exclusively breast fed. There are no concerns about his ability to feed. The parents don’t initially identify any particular symptoms. However on detailed questioning they say he has been posseting (reflux) more frequently, and been generally more unsettled. However his stools appear normal and he doesn’t have any respiratory symptoms. On examination the child does look thin, but you find no other abnormalities. hat are the possible causes of faltering growth in this baby?

Answer 1

Socioeconomic
No milk- get mum to express and see how much she’s producing
inadequate intake – how much are they feeding, should be waking them up in night to feed, ask about wet and dry nappies
Find out urine output to see if being absorbed but if poor stool eg blood or fatty malabsorption or if too much
Increased energy
GORD
CMPA
UTI

Question 2

How could you classify the causes of faltering growth?

Answer 2

Inadequate intake – eg socioeconomic, poor breast milk technique, unsuitable food offered, neglect. Pathology – impaired swallowing CP, cleft palate, anorexia secondary to chronic illness eg CF
Inadequate retention – GORD, vomiting
Malabsorption – IBD, CF, CMPA, cholestasis of liver, post-necrotising enterocolitis
Failure to utilise nutrients – chromosome disorders, IUGR, premature, metabolic disorder eg congenital hypothyroidism
Increased requirements – CF, thyrotoxicosis, cronic infection, malignancy, CHD, kidney disease

Question 3

What investigations for FTT and possetting?

Answer 3

History milk feeding
Withdraw milk from diet and see if theres a change - CMPA
FBC – immunodeficiency and anaemia
U+E, - renal failure and sodium shows nutrition
bone profile,- phosphate shows nutrition
LFTs- transaminase raised or albumin increased
Abg – metabolic problems
Skin prick test
PH testing possible for GORD
Urinalysis and culture – uti can cause FTT as well as possetting
Coeliacs screen
Sweat test - CF
TFTs
Immunoglobulins – immunodeficiency
Stool analysis for occult blood or parasites or reducing substances
Infection eg tb or hiv

Question 4

Would you advise giving additional formula feeds in FTT?

Answer 4

Depends on history but if worried then yes

Question 5

You ask for a urine sample to be tested by urinalysis. Large amounts of nitrites and leucocytes are found, suggesting what?

Answer 5

urinary tract infection.

Question 6

Name two possible causative organisms of UTIs?

Answer 6

E.coli
Klebsiella proteus
Pseudomonas
Staphylococcus saprophyticus.

Question 7

What antibiotic would you prescribe in the first line for UTI?

Answer 7

PO trimethoprim (if there is low risk of resistance), or nitrofurantoin (if eGFR ≥ 45ml/minute).

Question 8

Give two second line oral antibiotics which are also used in urinary tract infections.

Answer 8

Second line options include nitrofurantoin (if eGFR ≥ 45ml/minute) if it has not been used as a first-line option, amoxicillin (only if culture results available and susceptible), or cefalexin or cephalosporin

Question 9

What further investigations could you do for a UTI other than dipstick and what do they do?

Answer 9

U/S - looks for gross structural abnormalities eg hydronephrosis, abscess
MCUG (micturating cystourethrogram) - VUR
DMSA – radioisotope uptake – if work well then will pick up dye well and shine up and be scarred

Question 10

What factors affect your choice of investigations for UTIs? i.e. whats atypical

Answer 10

Age for ways of collecting urine
Do more extensive investigations if is an atypical presentation: septic, poor urine flow, abdo mass, raised creatinine, fail respond abx in 48 hrs, infection by other organism than e.coli

Question 11

Give most typical presentation for CMPA

Answer 11

Cows milk protein allergy – arching, don’t want feeds, young, blood and mucus in poo

Question 12

A 5 year old girl is referred because she has started soiling herself in the day. Until a year ago she had no problems with her bowels and had been out of nappies. However recently she has started passing small amounts of loose, watery stool at school. She says that she is unaware that she is doing this. On examination you find a mass in the left iliac fossa. The remainder of the examination is unremarkable. What is the most likely diagnosis in this case?

Answer 12

Constipation with overflow

Question 13

What are the possible causes of diarrhoea in children?

Answer 13

Gastroenteritis 
Hyperthyroidism  
Ibd  
Coeliacs 
Constipation  
Toddles diarrhoea – post viral gastroenteritis, food lumps made worse by milk

Question 14

What is overflow incontinence?

Answer 14

Overflow incontinence – hard mass is blocking the way so the only thing that can get around it is liquid so cannot consciously decide when to BO

Question 15

What would your management plan be for overflow incontinence?

Answer 15

Movicol first (osmotic) second line - senna (stimulant)
Need to get hard mass out
Disimpaction
Clean Oreo- when stools are clear 2/3 to shows works so just eat ice lollies, give them the laxative via NGT as have to have a lot of it to work

Question 16

List different meds for constipation and say what types they are

Answer 16

Movucol – first line and osmotic  
Lactulose – osmotic  
Sodium picofulfae – stimulate  
Busacodyl – stimulant 
Senna – stimulant  
Docusate – stool softener

Question 17

A four year old boy is referred to the paediatric ward because he has developed swelling around the face, scrotum and ankles. About 2 months ago he had a minor coryzal illness but has been otherwise fit and well. On examination he has swelling of the eyes, scrotum and ankles. He is afebrile. His abdomen is slightly distended and there is no rash. Urinalysis is performed and large amounts of protein are found but no blood. His weight is 17kg. What is the most likely diagnosis?

Answer 17

Nephrotic syndrome - steroid sensitive- minimal change most common!!

Question 18

What are the causes of proteinuria in children?

Answer 18

Nephritic syndrome also causes proteinuria but with haematuria
Nephrotic syndrome due to:
Orthostatic proteinuria – first wee
Glomerular abnormal: minimal change, glomerulonephritis, abnormal glomerular basement membrane
increased GFR pressure
Hypertension
tubular proteinuria
Systemic disease: SLE, heoch-schonlein purpura
Infection
Alpert’s syndrome
Tubular: PKD, acute tubular necrosis, proximal renal tubular acidosis

Question 19

What are the specific diagnostic criteria for nephrotic syndrome?

Answer 19

4 things for nephrotic: hypoalbumin, oedema, proteinuria and hyperlipidaemia
may present with:periorbital oedema, scrotal/leg/ankle oedema, ascites, SOB due to pleural effusion, infection eg peritonitis, septic arthiritis, sepsis due to loss of protetive immunoglobulins loss in urine

Question 20

What are the features of Steroid sensitive nephrotic syndrome?

Answer 20

age between 1-10 yrs, no macroscopic haematuria, normal BP, normal complement levels, normal renal function

Question 21

What initial investigations would you fo for nephrotic syndrome?

Answer 21

FBC 
Blood pressure  
Urinalysisis 
Protein and creatinine ratio  
ESR 
U&E 
Bone profile 
Chicken pox status  
Antistrepsolin O or anti-DNAse B titres and throat swab 
Urine culture 
Hep B and C screen 
Complement C3 levels

Question 22

How would you manage nephrotic sydrome in a child as described before?

Answer 22

Corticosteroids – prednisolone !!!!
If don’t respond to steroids then biopsy  
Immunise  
Fluid balance 
Low salt diet  
Pen V 
Anti hypertensives  
VERY rare diuretics used - IV furosemide

Question 23

What steroids would you prescribe for nephrotic syn?

Answer 23

Prednisolone

Question 24

What is the prognosis for nephrotic syndrome?

Answer 24

A 1/3rd resolve directly, a 1/3rd have infrequent relapses, a 1/3rd have frequent relapses and needs steroids - so usually on steroids for a long time
<1% mortality – usually for the non minimal change ones

Question 25

What is the definition of a UTI?

Answer 25

Growth of bacteria in the urinary tract – 10 to the 5 number on organisms on a culture – so UTI can only be confirmed properly by culture

Question 26

What is acute pyelonephritis vs cystitis?

Answer 26

Acute pyelonephritis - infection of renal parenchyma, presenting with symptoms of systemic infection Acute cystitis - infection of bladder, presenting with voiding symptoms

Question 27

How does a UTI present in infants?

Answer 27

fever, vomiting, lethargy, irritable, poor feed, FTT. Abdo pain, jaundice, haematuria (most common to least common)

Question 28

What are sx of an upper UTI?

Answer 28

–Fever, septicaemic illness (with meningitis in infancy) –General malaise, vomiting –Loin/abdominal pain – older child –Failure to thrive, jaundice

Question 29

What are the sx of a lower UTI?

Answer 29

``` –Dysuria –Urinary frequency/urgency –Incontinence –Lower abdominal pain –Haematuria ```

Question 30

When should a urine sample be collected?

Answer 30

When they have UTI sx, fever of over 38 degrees, less than 3 months old

Question 31

How should a urine sample be collected?

Answer 31

MSU, clean catch (best), catheter, collect pad, suprapubic aspirate (SPA)

Question 32

What should should be analysed in a urine sample?

Answer 32

visual and dipstick (LOOK at nitrites and leucocyte esterase - high nitrites and no leucocytes = abx; high leukocytes and no nitrites = MCS)

Question 33

what makes a uti atypical?

Answer 33

septic, not e.coli causing, poor urine flow, abdo mass, raised creatinine, no response to abx within 48 hrs

Question 34

What makes a UTI recurrent?

Answer 34

2 UTIs with systemic symptoms or 3+ without

Question 35

mx of a UTI?

Answer 35

admit if systemically unwell or less than 3 months. Give PO abx for 3 days if well. Can give fluids and pain relief.

Question 36

When should a U/S be done for a UTI and why?

Answer 36

good for seeing size and obstruction. Do if less than 6 months. Look for vesicoureteric reflux---> A congenital abnormality with a posterior urethra that causes retrograde flow of urine from bladder into ureter/ pelvicalyceal system/intrarenal --> looks dilated and torturous

Question 37

When should a DMSA scan be done for a UTI and why?

Answer 37

radionucleotide imaging, shows renal scarring and function. Do if <3 months, recurrent UTI or atypical UTI

Question 38

how may oedema present?

Answer 38

can cause pitting oedema, ascites, pleural effusions, pulmonary oedema , PERIORBITAL

Question 39

What causes oedema?

Answer 39

An increase in interstitial fluid – Oedema can be caused by lymphoedema eg due to Turners, venous obstruction eg VTE, low oncotic pressure due to low albumin eg from malnutrition or liver problems or increased loss from kidney, salt and water retention eg heart failure, kidney low GFR

Question 40

What are the key sx of nephrotic syndrome?

Answer 40

proteinuria --> hypoalbuminaemia ---> oedema (plus hyperlipidaemia)

Question 41

How may the urine look in proteinuria?

Answer 41

frothy

Question 42

What are the different types of nephrotic syndrome?

Answer 42

congenital (<1 yrs), steroid sensitive, steroid resistant

Question 43

how does steroid sensitivity nephrotic syndrome present?

Answer 43

``` –Normal BP –No macroscopic haematuria –Normal renal function –No features to suggest nephritis –Respond to steroids ```

Question 44

how does steroid resistant nephrotic syndrome present?

Answer 44

``` • Elevated BP • Haematuria • May be impaired renal function • Features may suggest nephritis • Failure to respond to steroids ```

Question 45

What is the usual histology on a steroid sensitive nephrotic syndrome in a child? What is the next most common?

Answer 45

most common: minimal change (no change seen under microscope) then Focal segmental glomerulosclerosis (scarring kidney)

Question 46

Ix for nephrotic syndrome?

Answer 46

initially: Proteinuria – first morning urine sample, with the protein: creatinine ratio raised blds: Albumin, FBC, clotting, ESR, U&Es, cholesterol and blood glucose consider further ix if doesnt resolve eg kidney biopsy or US

Question 47

Mx for nephrotic syndrome?

Answer 47

Prednisolone for steroid sensitive Consider diuretics, salt and sodium moderation, ACE-i, Pen V + vaccines to prevent infections Remember AKIs and inreased risk of thromboembolism

Question 48

What are the key sx for glomerulonephritis?

Answer 48

``` Haematuria – normally macroscopic Proteinuria Oedema (this and htn due to salt and water retention) Htn reduced UO ```

Question 49

What ix should be done glomeulonephritis and what does it show?

Answer 49

–FBC – mild normochromic, normocytic anaemia –U&Es – increased urea and creatinine, (impaired GFR)(hyperkalaemia, acidosis) –Immunology – raised ASOT/antiDNAse B titre, low C3, C4 –Throat /other swabs Urinalysis: –Haematuria – usually macroscopic –Proteinuria – dipstick, protein:creatinine –Microscopy – RBC cast

Question 50

Most common cause of glomeulonephritis?

Answer 50

Post-strep nephritis from grp A Nasopharyngeal/ skin infection roughly 10 days post-infection

Question 51

Mx of glomeulonephritis?

Answer 51

Fluid balance – measure input and output, moderate fluids, give diuretics and restrict salts Mx htn: diuretics etc Correct any other imbalances eg potassium or acidosis Dialysis if severe Penicillin for strep infection

Question 52

What is henoch schonlein purpura (HSP)?

Answer 52

Vasculitis with a palpable rash of skin, joints, gut and kidneys Caused by IgA deposition

Question 53

What is the pneumonic for remmbering HSP sx?

Answer 53

REMEMBER RAAR from most common symptoms to least: rash, arthirits, abdo pain and renal involvement (can present with nephrotic and nephritic syndrome)

Question 54

mx for HSP?

Answer 54

diagnosis is clinical | need immunosuppression, though steroid resistant

Question 55

ix for a child with faltering growth?

Answer 55

``` FBC - anaemia, immune deficiency U+Es- renal or metabolic problems LFT- liver disease, malabsorption TFT- hypothyroidism CRP + ESR- inflammation ferritin- iron defiency anaemia urine dipstick- UTI stool microscopy and culture- infection or parasites karyotype- turners sweat test- CF Total IgA, Anti-endomysial IgA, tissue transglutaminase IgA- coeliacs ```

Question 56

What are causes of FTT? (Think inadequate intake, inadequate retention, malabsorption, increased requirements)

Answer 56

inadequate intake: environmental issues; psychosocial factos; neglect; impaired suck/ swallow eg cleft palate or CP or SOB; anorexia from chronic illness inadequate retention: GORD Malabsorption: coeliacs, CF, CMPA, cholestatic liver disease, necrotising enterocolitis Incresed requirements: thyrotoxicosis, CF, malignancy, congenital heart disease, CKD, endocrine

Question 57

What causes GORD?

Answer 57

Due to sphincter immaturity- acid damaged oesophagus

Question 58

What are the sx of GORD?

Answer 58

Sx: due to regurgitation: poor weight gain, N+V, due to oesophagitis: dysphagia, irritable, haematemesis, anaemia, chest/gastric pain, refuse to eat as it hurts, pull ears, throw head back to clear throat, Resp sx: aspiration pneumonia, wheeze, apnoea, cough, stridor, hoarse, hiccups, neuro sx: Sandifer's syndrome

Question 59

What is Sandifers syndrome?

Answer 59

Sandifer's = spasmodic torticollis and dystonia. Nodding and rotation of the head, neck extension, gurgling, writhing movements of the limbs, and severe hypotonia have also been noted. associated with GORD

Question 60

ix for GORD?

Answer 60

24 hr pH probe/ impedence study, barium swallow, endoscopy, see if respond to PPI - if diagnosis unclear or complications

Question 61

mx for GORD?

Answer 61

Mx: ranitidine, food play, thicken feeds, positioning PPI, fundoplication if severe

Question 62

complications of GORD?

Answer 62

FTT, oesophagitis, aspiration, sandifers

Question 63

How does CMPA present?

Answer 63

``` Iron deficiency anaemia Vomiting Asthma Eczema Refuse to feed Diarrhoea/ constipation Blood in stool Rash Swelling eye lids Colic Irritable Wheeze and cough ```

Question 64

mx of CMPA?

Answer 64

Management: eliminate milk frm mums diet and use AA feed

Question 65

what are the infective causes of diarrohoea?

Answer 65

``` Enterovirus eg rotavirus, adenovirus Bacterial eg c. Diff, salmonella Parasite eg Giardia TB Post-infective: Mucosal damage -> antigen exposure -> inflammation -> lose enzymes (disaccharides) -> diarrhoea ```

Question 66

IgE vs non IgE mediated food intolerance presentation?

Answer 66

IgE- angioedma, pruritus, urticria, resp sx, eyrthema, diarrhoea and constipation, colicky abdo pain non-IgE-diarrohea, constiption, colicky abdo pain, blood or mucus in stool, GORD, perianal redness

Question 67

What is coeliacs?

Answer 67

Proximal small intestine damage as gliadin causes an immunological response that means enterocytes increase but are insufficient to compensate for villous cell loss at tips genetic cause

Question 68

How does coeliacs present?

Answer 68

Sx: osteopenia, distended abdo, thin arms and legs (when severe), abnormal stool, irritable, anaemia, other gastro sx 8-24 months presentation

Question 69

What are the differentials for coeliacs?

Answer 69

IBS, toddlers diarrhoea, disaccaride defieicency, lactose intolerant

Question 70

What ix should you do for coeliacs?

Answer 70

Tissue transglutaminase antibodies and endomysial antibody test Always do IgA assay total in case of false negatives Biopsy gold standard (would see crypt hyperplasia and villous atrophy) but avoid if lab results indicate high chance of coeliacs

Question 71

What criteria is used for histological diagnosis of coeliacs?

Answer 71

Modified marsh criteria for diagnosis of histological findings

Question 72

mx of coeliacs?

Answer 72

gluten free, test for other autoimmune problems (T1DM and thyroid), if don’t follow diet increased risk of cancers

Question 73

How does lactose intolerance present?

Answer 73

Explosive watery stools, abdominal distension, flatulence, audible bowel sounds

Question 74

ix for lactose intolerance?

Answer 74

Stool chromatography, Lactose hydrogen breath test, Small bowel biopsy and elimination diet

Question 75

mx for lactose intolerance?

Answer 75

Lactose free formula/Milk-free diet with calcium and Vitamin D supplements

Question 76

what is Toddlers diarrohea?

Answer 76

Toddlers diarrhoea: get undigested food in poo, treat with high fat and low juice and sugars diet

Question 77

What is regurgitation vs rumination vs possetting?

Answer 77

* Regurgitation: effortless expulsion of gastric contents (healthy infants and older children who eat in excess) * Rumination: frequent regurgitation of ingested food (largely behavioural) * Possetting – small volume vomits during or between feeds in otherwise well child

Question 78

What should be asked in the hx for a vomiting child?

Answer 78

Blood? Bilous? Projectile? headache, changes in vision, polyuria, polydipsia and weight loss, to rule out increased intracranial pressure or DKA. Dehydration – mucus membranes, skin turgor, fontanelle, urine and stool output

Question 79

important/ common neonate causes and signs involving vomiting?

Answer 79

malrotation/ volvulus - bilous vomit, obstruction Hirschsprung – delayed passage of meconium, distension, bilous vomiting NEX- premmie, bilous vomit, distension infection - pyrexia and tachycardia

Question 80

important/ common infant causes of vomiting?

Answer 80

GORD- vomit with feeds food intolerance- loose stools/ constipation, eczema Pyloric stenosis – progressive projectile vomiting, low potassium, low chloride, metabolic acidosis Intussuception –colciky pain, bilious vomit, red jelly stool Strangulated hernia/ adhesion – bilous vomit/ abdo pain Raised ICP – early morning vomit, bulging fontanelle infection CMPA UTI

Question 81

important/ common older child causes of vomiting?

Answer 81

Appendicitis – anorexia, central pain to RIF, vomit, pyrexia – appendectomy strangulated hernia Pancreatitis – abdo pain DKA – polyuria, polydipsia, hyperglycaemia, ketonuria, metabolic acidosis OD and psychiatric infection pregnancy

Question 82

ix for acute vomiting?

Answer 82

U&E, stool virology, abdominal X-ray, surgical opinion, exclude systemic disease

Question 83

ix for chronic vomiting?

Answer 83

Chronic: FBC, ESR/CRP, U&E, LFT, H pylori serology, Urinalysis, Upper GI endoscopy, Abdominal ultrasound, Small bowel enema, Brain imaging, test feed

Question 84

ix for cyclic vomiting?

Answer 84

Cyclic: amylase, lipase, glucose, ammonia

Question 85

what are the complications of vomiting?

Answer 85

Potassium deficiency Alkalosis Sodium depletion Nutritional Mallory-Weiss - Tears of the short gastric arteries resulting in shock and hemoperitoneum Dental: erosions and caries Oesophageal stricture, Barrett’s metaplasia, broncho-pulmonary aspiration, FTT, anaemia

Question 86

Give an example of a antihistamine anti emitic?

Answer 86

clyclizine | promethazine

Question 87

Give an example of a dopamine antoginst anti emitic?

Answer 87

prochlorperazine metoclopramide droperidol

Question 88

Give an example of a serotin antagonist anti emitic?

Answer 88

ondansetron

Question 89

Give the Rome II criteria for constipation?

Answer 89

►Two or fewer defecations per week ►At least 1 episode of faecal incontinence per week ►Retentive posturing or stool retention. ►Painful or hard bowel movements ►Presence of a large faecal mass in the rectum ►Large diameter stools that may obstruct the toilet

Question 90

What are the differentials for constipation in children?

Answer 90

``` hirschsprungs disease anorectal malformations Neuronal intestinal dysplasia Spina bifida Neuromuscular disease Hypothyroidism Hypercalcaemia Coeliac disease Food allergy/intolerance Cystic fibrosis Perianal group A streptococcal infection Anal fissure Pelvic/spinal tumours Child sexual abuse Drugs ```

Question 91

What are complications of constipation?

Answer 91

acquired megacolon, anal fissures, overflow incontinence, behavioural problems

Question 92

mx of constipation?

Answer 92

``` Diet/fluids and exercise Behavioural advice Toilet training advice Simple reward schemes Laxatives enemas ```

Question 93

Give examples of softener laxatives?

Answer 93

lactulose, liquid paraffin

Question 94

Give example of bulking agent laxatives?

Answer 94

Fybogel

Question 95

Give examples of non absorbed laxative irrigative?

Answer 95

Movicol (first line in overflow incontinence)

Question 96

give example of stimultant laxative?

Answer 96

Senna, Dulcolax

Question 97

mx for anal fissure?

Answer 97

anaesthetic cream +/- vasodilator

Question 98

What are the features of diarrhoea?

Answer 98

Change in the consistency of stools (loose or liquid), and/or increase in the frequency of evacuations (typically >3 in 24 hours), with or without fever or vomiting which lasts less than 7 days and not longer than 14 days

Question 99

differentials for diarrhoea in children?

Answer 99

infections (gastroenteritis, otitis media, tonsillitis, pneumonia, septicaemia, UTI, meningitis), allergy, haemolytic uraemic syndrome, surgery, DKA, coeliacs, CMPA, lactose intolerance, adrenal induffieciency

Question 100

what are infective causes of gastroenteritis?

Answer 100

rotavirus!, campylobacter, giardia, shigella

Question 101

How else may gastroenteritis present apart from diarrhoea?

Answer 101

Dysentry eg shigella Fever Vomiting Dehydrated

Question 102

What must you always assess in a child with D+V?

Answer 102

Dehydration! | do CRT and skin turgor and feel fontanelle

Question 103

Signs of moderate dehydration (5%)?

Answer 103

``` Seems unwell Irritable or lethargic Lower urine output Eyes sunken Dry mucus membranes Tachycardia and pnoea Reduced skin turgor ```

Question 104

Signs of severe dehydration (10%)?

Answer 104

``` Decreased consciousness Pale or mottled skin Weak breathing and pulses Cold Prolonged CRT Hypotension Sunken fontanelle ```

Question 105

Mx of moderate dehydration?

Answer 105

oral rehydration solution | consider admitance to hospital, IV. NGT fluids

Question 106

Mx of severe dehydration?

Answer 106

ABG, glucose and U+Es before IV fluids | if in shock ABCDE, bolus

Question 107

How does Oral rehydration solution work?

Answer 107

works by being high in sodium and glucose as sodium is absorbed via a sodium and glucose transporter -> water passively follows

Question 108

When should stool microbiology be done?

Answer 108

``` suspect septicaemia or recently travel abroad or blood or mucus in the stool or the diarrhoea has not improved by day 7 or child is immunocompromised. ```

Question 109

What is hypernatraemia dehydration?

Answer 109

More water than sodium loss so the extracellular fluid becomes hypertonic and water moves from intra to extracellular -> less clinical signs, brain shrinkage Usually due to high insensible loss eg fever or hot environment Unusual and serious Irritable with doughy skin Rehydration should be slow

Question 110

What is Hyponatraemic/ isonatraemic dehydration ?

Answer 110

If drink lots of water/other hypotonic solutions means there is more sodium than water loss -> low plasma sodium -> water moves from extra to intracellular -> shock and increase brain volume

Question 111

Signs of crohns disease?

Answer 111

erythema nodusum, ulcers, FTT, abdo pain, diarrhoea, wt loss, fever, lethargy, perianal skin tags, uveitis, arthralgia

Question 112

Ix for IBD?

Answer 112

``` CRP ESR FBC (anaemia; thrombocytosis) Albumin (leaky gut so low) Acid glycoprotein (orosomucoid) Stool fecal calprotectin BIOPSY Small bowel imaging – narrowing, fissuring, bowel wall thicken ```

Question 113

signs of UC?

Answer 113

Rectal bleed, diarrhoea, colicky pain, FTT, wt loss, arthirits, eryhtema nodusum

Question 114

Difference between ulcertive colitis and crohns?

Answer 114

``` crohns: ►Mouth to anus ►Transmural inflammation ►Discontinuous, skip lesions ►Granuloma - non caseating ►Rectal sparing ►Fissures, fistula, abscesses and strictures ►Perianal disease Originates at terminal ileum ``` ``` Ulcerative colitis ►Colon only ►Mucosal inflammation ►Continuous ►No granuloma or rectal sparing ►Larger association with bowel cancer ►Abscesses and strictures rare ►Primary sclerosing chlangitis Can get complications of haemorrhage and toxic megacolon smoking improves ```

Question 115

mx of IBD?

Answer 115

EEN Corticosteroids Aminosalicytes (UC only) Abx Immunomodulators – azathioprine, methotrexate Biologics – infliximab, adalimumab (anti TNF) surgery

Question 116

What is a volvulus/ malrotation?

Answer 116

A type of obstruction where Bowel rotates in fetus, if mesentery is not fixed at start or end of SI the bowel is shorter and is predisposed to volvulus ladd bands most common cause

Question 117

How does volvulus present?

Answer 117

Sx: first few days of life, bilious vomit (bright green), abdo pain, tender from peritonitis or ischaemic bowel

Question 118

Ix and mx for volvulus?

Answer 118

Ix: upper GI contrast study unless signs of vascular compromise then do surgery as emergency mx: surgery

Question 119

What is pyloric stenosis?

Answer 119

narrowing of pylorus due to muscle hypertrophy meaning stomach contents cant properly enter SI

Question 120

What can cause pyloric stenosis?

Answer 120

erythromycin

Question 121

How does pyloric stenosis present?

Answer 121

Presents at age 2-8 weeks age progressive, projectile vomiting (clear the cot), hungry after vomit under severe dehydration, weight loss later, Metabolic alkalosis with hypokalaemia, hypocholoraemia

Question 122

How may pyloric stenosis be ix?

Answer 122

Given test feed, observe for gastric peristalsis, olive like above umbilicus (RUQ,) US to confirm

Question 123

mx for pyoric stenosis?

Answer 123

1. correct fluids and electrolytes | 2. pyloromyotomy (divide hypertrophied muscle down to the mucosa)

Question 124

What is intussusception and the pathophysiology?

Answer 124

Invagination of the proximal bowel into distal – mostly ileum into caecum through the valve there – mesentery goes with – blood vessels go with -> ischaemic

Question 125

cause of intussusception?

Answer 125

Unknown what causes, suggested that infection causing enlargement of peyer’s patches possible cause

Question 126

how does intussusception present?

Answer 126

Typically present between 3M to 2yrs scream then go flat, pale and draw up legs and vomit then scream again, bring up bile eventually, paroxysmal, colicky, palpable sausage shaped mass, redcurrant jelly stool ie blood stained mucus (seen later stages, poss PR), abdo distended, shock Normally have gastroenteritis at the same time

Question 127

ix of intussusception?

Answer 127

XR abdo, U/S

Question 128

mx of intussusception?

Answer 128

fluids, radiologist does air enema to push bowel back, if that fails do surgery

Question 129

What is a Meckel diverticulum?

Answer 129

Due to ileal remnant of the villeo intestinal duct aka the meckel diverticulum which contains ectopic gastric mucosa/ pancreatic tissue Mostly asx but can lead to intussusception or volvulus

Question 130

What is hirschprungs disease?

Answer 130

No ganglion cells in plexuses of rectum

Question 131

what is the presentation and ix of hirschprungs disease?

Answer 131

Present with no muconeum first 24 hrs, distended and bile stained vomit, tight anus, empty rectum Diagnose with suction rectal biopsy

Question 132

what is the mx of hirschprungs disease?

Answer 132

Do surgery to have colostomy and then anastamose normal bowel to anus

Question 133

what is the presentation of appendicitis?

Answer 133

Uncommon under age of 3 Fever – low grade ie 37-38 Anorexia Colciky pain, made worse by movement eg walking, cough, bumps on road on journey there Generalised abdo pain then becomes RIF (as appendix becomes more inflammed it toucher peritoneum -> peritonitis) Pain is generally due to stretching of colon stretching peritoneum Vomiting as affects and dilates entire bowel

Question 134

What would you find O/E for appendictis?

Answer 134

O/E guarding, local and rebound tenderness in RIF (mcburneys point), sore on percussion If retrocecal guarding may be absent Rovsing's sign may be positive: palpation of the left lower quadrant increases the pain felt in the right lower quadrant. This pressure stretches the entire peritoneal lining, and so causes pain in any location where the peritoneum is irritating the muscle.

Question 135

What ix could you do for appendicits?

Answer 135

Ix: do CRP, FBC for WCC, possibly US can show thickened appendix with abscess or perforation - unreliable investigations so best to do regular review

Question 136

What is a possible complication of untreated appendictis and how does it present?

Answer 136

peritonitis - | generalised guarding, unwell, distressed, high fever

Question 137

what is the mx of appendicitis

Answer 137

IF perforated then abx before surgery | Mx: abx, surgery

Question 138

What are some differentials for RIF pain in children?

Answer 138

Teenage girls – think gynae ovarian torsion or ectopic (UPT and US) Mesenteric adenitis – non specific abdo pain, to do wtih lymph nodes Check for strangulated hernia or testicular torsion in boys – as sympathetic chain goes up to mid abdomen, so ask about testicular pain Lower lobe pneumonia – ask about cough etc. DKA- polyuria, polydipsia Hepatitis – jaundice, RUQ, N+V, tired Pancreatitis - check serum amylase UTI - always do dipstick

Question 139

What is meconium ileus?

Answer 139

Usually delayed passage of meconium and abdominal distension associated mircocolon The majority have cystic fibrosis X-Rays will not show a fluid level as the meconium is viscid, PR contrast studies may dislodge meconium plugs and be therapeutic Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs

Question 140

What is meconium plug?

Answer 140

A meconium plug is poo enclosed in a mucus coat which is often more difficult for your baby to pass. Some babies may pass just one plug, others pass more. Your baby may pass this plug: spontaneously

Question 141

What is anal stenosis of the newborn?

Answer 141

Anal stenosis accounts for approximately 20 percent of anorectal malformations.4 The anus is very small, and a central black dot of meconium is present. Intense efforts are required to pass a ribbon-like stool. The diagnosis of anal stenosis is established by demonstration of a small, tight anus

Question 142

Describe necrotising enterocolitis

Answer 142

Prematurity is the main risk factor Early features include abdominal distension and passage of bloody stools X-Rays may show pneumatosis intestinalis and evidence of free air Increased risk when empirical antibiotics are given to infants beyond 5 days Treatment is with total gut rest and TPN, babies with perforations will require laparotomy

Question 143

What are the most common causes of nephritis in children and what is their mechanism?

Answer 143

post-strep -immune complexes made up of streptococcal antigens, antibodies and complement proteins get stuck in the glomeruli of the kidney and cause inflammation IgA nephropathy/ bergers disease - IgA deposits in the nephrons of the kidney causes inflammation