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MSRA Content > Level 1 - GI COPY COPY > Flashcards

Level 1 - GI COPY COPY Flashcards

1
Q

What is constipation?

A
  • A decrease in the frequency of bowel movements characterized by the passing of hard stools, which may be large and associated with straining and pain
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2
Q

What is soiling?

A
  • Soiling of the clothes (the involuntary passage of fluid or semi-solid stool) may result from overflow from the overloaded bowel, and stool retention (faecal impaction) may occur
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3
Q

What is normal stool frequency in children?

A
  • In the UK, normal stool frequency in children ranges from an average of 4 per day in the first week of life to 2 per day at 1 year of age.
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4
Q

What is normal stool frequency in adult?

A
  • The normal adult range (between 3 stools per day and 3 stools per week) is usually attained by 4 years of age.
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5
Q

What is idiopathic constipation?

A
  • Constipation is termed idiopathic (functional) if it cannot be explained by any anatomical or physiological abnormality
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6
Q

Define chronic constipation?

A
  • Chronic constipation lasts >8 weeks
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7
Q

Epidemiology of constipation?

A
  • Around 3% of paediatric consultations
  • In the UK, 30% of children aged 4–11 years will have constipation lasting less than 6 months
  • Peak incidence is at time of toilet training (2-3 years of age)
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8
Q

Risk factors for constipation?

A

o Pain, fever, inadequate fluid intake, reduced dietary fibre intake, toilet training issues

o Drugs (sedating antihistamines, opiates)

o Psychosocial issues and family history

o Sexual Abuse

o Physically inactive (cerebral palsy)

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9
Q

Pathological causes of constipation?

A

o Hirschsprung disease

o Coeliac disease

o Anorectal disorders

o Hypothyroidism

o Hypercalcaemia

o Neurodegenerative disorder (Down’s/ASD)

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10
Q

Symptoms of constipation?

A

o <3 complete stools per week

o Hard. Large stools

o Rabbit droppings stools

o Overflow soiling

o Distress or pain on passing stool

o Bleeding

o Straining

o Poor appetite

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11
Q

What is overflow soiling?

A

 Typically very loose, smelly stools which are passed without sensation or awareness

 Overdistended rectum loses feeling of need to defecate

 As newer, looser stool continues to be made in the intestines, it leaks around the large chunk of hard stool

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12
Q

Signs of constipation?

A

o Rectal tears etc

o Palpable mass felt in LIF

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13
Q

Red flags in constipation?

A

o Failure to pass meconium in 48 hours (Hirschsprung disease)

o Failure to thrive (hypothyroidism, coeliac disease)

o Gross abdominal distension (Hirschsprungs)

o Sacral dimple over spine (Spina bifida)

o Perianal fistulae, abscesses (Crohns disease)

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14
Q

Investigations needed in constipation?

A
  • No specific investigations if no pathology suspected
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15
Q

If pathology suspected, what investigations should be done in constipation?

A

o FBC

o Coeliac antibody screen

o TFTs o Serum calcium

o Abdominal x-ray

o Rectal biopsy (Hirschsprung’s disease)

o Spinal imaging

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16
Q

General management of constipation?

A
  • Aim is to achieve disimpaction and then maintenance therapy:
  • Reassure patient and child that it is common, and soiling is involuntary
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17
Q

Dietary advice in constipation?

A

o Increase fibre (fruit, vegetables, bread, baked beans)

o Advise normal daily physical activity

o Increase fluid intake

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18
Q

Behavioural therapy in constipation?

A

o Reward child for good toilet routine

o Go at similar time each day

o 5 mins after meals for toilet time, star charts and rewards for passing stools

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19
Q

Acute disimpaction medication for constipation?

A

o Movicol stool softener

o If fails after 2 weeks then add stimulant laxative (Senna)

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20
Q

Maintenance laxative treatment in constipation?

A

o Movicol stool softener

o If constipation persists, add stimulant laxatives (Senna)

o If diarrhoea occurs, then reduce dose suitably

o Continue for several weeks until regular soft stools achieved

21
Q

Complications of constipation?

A
  • Anal Fissure
  • Haemorrhoids
  • Rectal Prolapse
  • Megarectum
  • Faecal impaction and soiling
22
Q

Define gastroenteritis?

A
  • Gastroenteritis is a transient disorder due to enteric infection with viruses, bacteria, or parasites
  • Characterized by the sudden onset of diarrhoea, with or without vomiting
23
Q

What is acute diarrhoea?

A

 >3 episodes of watery stool in a day lasting for <14 days

24
Q

What is persistent diarrhoea?

A

 Diarrhoea lasts >14 days

25
Q

What is dysentery? What organisms responsible for dysentery?

A

 Loose stools with blood and mucus

 Organisms that cause bloody diarrhoea include campylobacter, entamoeba histolytica, E.coli, salmonella serotypes and Shigella

26
Q

What is Traveller’s diarrhoea?

A

 Diarrhoea starting during or shortly after foreign travel

 Organism most commonly E.coli, Salmonella, Viruses, Cryptosporidium, Giardia

27
Q

Epidemiology of gastroenteritis?

A
  • Major cause of mortality in developing countries
  • 10% of under 5 year olds have gastroenteritis
  • Rotavirus part of childhood vaccination schedule
28
Q

Viral causative organisms in gastroenteritis?

A

 Rotavirus

 Norovirus

 Adenovirus

29
Q

Bacterial causative organisms in gastroenteritis?

A

 Campylobacter jejuni (severe abdominal pain)

 E.coli (profuse, rapidly dehydrating diarrhoea)

 Salmonella (dysentery)

 Shigella (dysentery, high fever)

 Yersinia enterocolitica

30
Q

Sources of infection in gastroenteritis?

A

o Contaminated water,

o Poor food hygiene (meat, fresh produce, chicken, eggs, previously cooked rice)

o Faecal oral route

31
Q

Symptoms and signs of gastroenteritis?

A
  • Diarrhoea
  • Dysentery (blood and mucus in diarrhoea)
  • Vomiting
  • Cramping abdominal pain
  • Fever
  • Dehydration/shock
  • Electrolyte imbalance
  • Malaise
32
Q

DDx of gastroenteritis?

A
  • Systemic infection o Sepsis, meningitis - Local Infections o RTI, otitis media, Hep A, UTI - Surgical Disorders o Pyloric stenosis, intussusception, acute appendicitis, necrotising enterocolitis, Hirschsprung disease - Diabetic ketoacidosis - HUS - Coeliac disease, cow’s milk protein intolerance
33
Q

Investigations in gastroenteritis?

A
  • Stool culture
  • Bloods

U&E’s, glucose

  • Dehydration assessment

o No clinical dehydration detectable (usually <5% of body weight)

o Clinical dehydration (usually 5-10%)

o Shock (usually >10% dehydration)

34
Q

What are symptoms of clinical dehydration?

A

Unwell, irritable, lethargy, decreased urine output, warm extremities, sunken eyes, dry mucous membranes, tachycardia, tachypnoea, reduced skin turgor

35
Q

Symptoms of clinical shock?

A

Decreased conscious level, pale/mottled, cold extremities, tachycardia, tachypnoea, weak pulses, prolonged cap refill, hypotension

36
Q

Fluid management of gastroenteritis when no signs of dehydration?

A

 Continue breast-feeding and other milk feeds

 Encourage fluid intake to compensate increased losses

 Oral rehydration solution (ORS) (50ml/kg over 4h) prescribed as supplemental fluid

37
Q

Fluid management of gastroenteritis when clinical dehydration?

A

 ORS regularly

 Give oral fluid deficit replacement (50ml/kg) over 4 hours, if tolerating oral - PRN/Once only meds

 If struggling to feed, consider NG tube

 Continue breast-feeding

 If deterioration, IV therapy with fluid deficits and maintenance fluids

 Monitor plasma electrolytes, U&Es, creatinine and glucose

38
Q

Fluid management of gastroenteritis with shock?

A

 Rapid IV of 0.9% NaCl bolus infusion, repeat if necessary

 If deterioration, IV therapy with fluid deficits and maintenance fluids

 Monitor plasma electrolytes, U&Es, creatinine and glucose

39
Q

After rehydration, what management should be given in gastroenteritis?

A

o Give full strength milk

o Avoid fruit juice and carbonated drinks

o Advise diligent hand-washing, not to towel share, do not return to school until 48 hours after symptoms stop - DO NOT ANTI-DIARRHOEAL DRUGS AND ANTI-EMETICS

40
Q

When would you give antibiotics in gastroenteritis?

A

o Indicated for sepsis, extra-intestinal spread, salmonella gastroenteritis if <6 months old or for specific bacterial or protozoal infections (C.diff with colitis, cholera, shigellosis, giardiasis)

41
Q

Complications of gastroenteritis?

A
  • Malnutrition
  • Temporary sugar intolerance after D&V
  • Post-gastroenteritis lactose intolerance common
  • Post-enteritis enteropathy
42
Q

What is GORD? When does it usually resolve? What is reflux disease?

A
  • GORD is a condition where there is reflux of gastric contents (particularly acid, bile, and pepsin) back into the oesophagus
  • Usually resolves within first year of life
  • Non-forceful regurgitation into oesophagus

Reflux disease is when you get negative side effects

43
Q

Causes of GORD?

A

o Transient relaxation (reduced tone) of the LOS – functional immaturity

o Increased intra-gastric pressure (for example straining and coughing)

o Delayed gastric emptying

o Impaired oesophageal clearance of acid Floppy children - Down’s syndrome

44
Q

Risk factors for GORD?

A

o Fluid diet, horizontal stature and short intra-abdominal length of oesophagus

o Cerebral palsy

o Preterm infants

o Following surgery for oesophageal atresia or diaphragmatic hernia

45
Q

Symptoms and signs of GORD?

A
  • Recurrent regurgitation/vomiting
  • Possetting
  • May contain some blood
  • Increased salivations
  • Failure to thrive
  • Chronic cough
  • Normal weight and otherwise well - often
46
Q

Diagnosis of GORD? When to use other tests?

A
  • Diagnosed is clinical usually

Other tests:

o FBC

o 24-hour oesophageal pH monitoring to quantify degree of reflux

o Endoscopy with biopsies

o Barium swallow/Oesophageal monometry can exclude underlying abnormalities - If treatment resistant then use other tests to identify cause

47
Q

General management of GORD?

A
  • Reassure, don’t overfeed
  • Position at 30o head-up prone position after feeds
  • Dietary: Thickened milk feeds (Carobel), small frequent meals, avoid food before sleep, avoid fatty foods, caffeine, citrus juices, alcohol, smoking
48
Q

Drug therapy in GORD? Surgery?

A

• Drugs:

 Gaviscon added to feeds (antacid and alginate forms viscous layer)

 Gastric acid reducing drugs - H2 receptor antagonists (ranitidine) or PPI (omeprazole)

 Enhance gastric emptying (domperidone)

• Surgery if failed medical therapy

 Fundoplication – fundus of stomach wrapped around intra-abdominal oesophagus

49
Q

Complications of GORD?

A
  • Failure to thrive
  • Oesophagitis – haematemesis and iron deficiency anaemia
  • Recurrent pulmonary aspiration – pneumonia, wheeze
  • Dystonic neck posturing (Sandifer syndrome – extension and lateral turning of head)

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