Level 1 - GI COPY COPY Flashcards
What is constipation?
- 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
What is soiling?
- 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
What is normal stool frequency in children?
- 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.
What is normal stool frequency in adult?
- The normal adult range (between 3 stools per day and 3 stools per week) is usually attained by 4 years of age.
What is idiopathic constipation?
- Constipation is termed idiopathic (functional) if it cannot be explained by any anatomical or physiological abnormality
Define chronic constipation?
- Chronic constipation lasts >8 weeks
Epidemiology of constipation?
- 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)
Risk factors for constipation?
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)
Pathological causes of constipation?
o Hirschsprung disease
o Coeliac disease
o Anorectal disorders
o Hypothyroidism
o Hypercalcaemia
o Neurodegenerative disorder (Down’s/ASD)
Symptoms of constipation?
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
What is overflow soiling?
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
Signs of constipation?
o Rectal tears etc
o Palpable mass felt in LIF
Red flags in constipation?
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)
Investigations needed in constipation?
- No specific investigations if no pathology suspected
If pathology suspected, what investigations should be done in constipation?
o FBC
o Coeliac antibody screen
o TFTs o Serum calcium
o Abdominal x-ray
o Rectal biopsy (Hirschsprung’s disease)
o Spinal imaging
General management of constipation?
- Aim is to achieve disimpaction and then maintenance therapy:
- Reassure patient and child that it is common, and soiling is involuntary
Dietary advice in constipation?
o Increase fibre (fruit, vegetables, bread, baked beans)
o Advise normal daily physical activity
o Increase fluid intake
Behavioural therapy in constipation?
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
Acute disimpaction medication for constipation?
o Movicol stool softener
o If fails after 2 weeks then add stimulant laxative (Senna)
Maintenance laxative treatment in constipation?
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
Complications of constipation?
- Anal Fissure
- Haemorrhoids
- Rectal Prolapse
- Megarectum
- Faecal impaction and soiling
Define gastroenteritis?
- 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
What is acute diarrhoea?
>3 episodes of watery stool in a day lasting for <14 days
What is persistent diarrhoea?
Diarrhoea lasts >14 days
What is dysentery? What organisms responsible for dysentery?
Loose stools with blood and mucus
Organisms that cause bloody diarrhoea include campylobacter, entamoeba histolytica, E.coli, salmonella serotypes and Shigella
What is Traveller’s diarrhoea?
Diarrhoea starting during or shortly after foreign travel
Organism most commonly E.coli, Salmonella, Viruses, Cryptosporidium, Giardia
Epidemiology of gastroenteritis?
- Major cause of mortality in developing countries
- 10% of under 5 year olds have gastroenteritis
- Rotavirus part of childhood vaccination schedule
Viral causative organisms in gastroenteritis?
Rotavirus
Norovirus
Adenovirus
Bacterial causative organisms in gastroenteritis?
Campylobacter jejuni (severe abdominal pain)
E.coli (profuse, rapidly dehydrating diarrhoea)
Salmonella (dysentery)
Shigella (dysentery, high fever)
Yersinia enterocolitica
Sources of infection in gastroenteritis?
o Contaminated water,
o Poor food hygiene (meat, fresh produce, chicken, eggs, previously cooked rice)
o Faecal oral route
Symptoms and signs of gastroenteritis?
- Diarrhoea
- Dysentery (blood and mucus in diarrhoea)
- Vomiting
- Cramping abdominal pain
- Fever
- Dehydration/shock
- Electrolyte imbalance
- Malaise
DDx of gastroenteritis?
- 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
Investigations in gastroenteritis?
- 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)
What are symptoms of clinical dehydration?
Unwell, irritable, lethargy, decreased urine output, warm extremities, sunken eyes, dry mucous membranes, tachycardia, tachypnoea, reduced skin turgor
Symptoms of clinical shock?
Decreased conscious level, pale/mottled, cold extremities, tachycardia, tachypnoea, weak pulses, prolonged cap refill, hypotension
Fluid management of gastroenteritis when no signs of dehydration?
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
Fluid management of gastroenteritis when clinical dehydration?
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
Fluid management of gastroenteritis with shock?
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
After rehydration, what management should be given in gastroenteritis?
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
When would you give antibiotics in gastroenteritis?
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)
Complications of gastroenteritis?
- Malnutrition
- Temporary sugar intolerance after D&V
- Post-gastroenteritis lactose intolerance common
- Post-enteritis enteropathy
What is GORD? When does it usually resolve? What is reflux disease?
- 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
Causes of GORD?
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
Risk factors for GORD?
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
Symptoms and signs of GORD?
- Recurrent regurgitation/vomiting
- Possetting
- May contain some blood
- Increased salivations
- Failure to thrive
- Chronic cough
- Normal weight and otherwise well - often
Diagnosis of GORD? When to use other tests?
- 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
General management of GORD?
- 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
Drug therapy in GORD? Surgery?
• 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
Complications of GORD?
- 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)
