Paediatric Gastro Flashcards
signs of dehydration in babies?
- sunken fontenelles
- dry mucus membranes
- reduced skin turgor
- prolonged CRT
- reduced urine output/wet nappies
- tachycardia and tachypnoea (non specific)
what is the typical abnormality seen on blood gas analysis in pyloric stenosis?
metabolic alkalosis
non bilious vomiting = only stomach acid juices are lost so
hypo cl- and hypo k+
and more HCO3-
history:
1 year old pulling up knees since this morning and screaming for the last 20 minutes (inconsolable)
looks white
vomiting green x3 with blood and BNO
decreased oral intake
what are you thinking for bilious vomiting and BNO?
what if it were a newborn?
lower bowel obstruction
likely intussusception
newborn: suggestive of congenital obstructive GI malformations, such as duodenal/jejunal atresias, malrotation with midgut volvulus, meconium ileus or plugs, and Hirschsprung disease.
what is pyloric stenosis and how does it classically present?
what clinical signs might you see?
what imaging might you do?
what kind of emergency is it?
Pyloric stenosis is the hypertrophy of the pyloric muscles at the outlet of the stomach.
NEWBORN
classic presentation: projectile, non-bilious vomiting immediately following feeds that presents in the first few weeks of life.
Infants are classically firstborn males with a positive family history of pyloric stenosis, and may have visible abdominal peristalsis or a palpable olive-shaped mass near the umbilicus.
Abdominal ultrasound is the modality of choice to assess for suspected pyloric stenosis.
It is considered a medical (and surgical) emergency due to the risk of severe electrolyte disturbances – classically, a hypochloremic hypokalemic metabolic alkalosis.
what is duodenal atresia?
how does it classically present?
what clinical signs are there?
what might you see on abdo x ray?
Duodenal atresia is the congenital absence of a portion of the first part of the small bowel.
Symptoms typically present shortly after birth. They may present with either bilious or non-bilious vomiting, depending whether the atresia is distal or proximal to the ampulla of Vater, the site where bile and pancreatic enzymes are released into the duodenum from the common bile duct.
It typically does not present with abdominal distension.
A classical x-ray finding associated with duodenal atresia is the ‘double bubble sign.’
what is malrotation?
what does it present as?
what type of emergency is it treated as?
intestinal malrotation - congenital anomaly in rotation of the midgut as it forms
presents as intermittent bilious vomiting, usually with significant abdominal distension. It may be associated with severe abdominal pain if associated with midgut volvulus causing bowel ischemia. Since the bowel obstruction is often intermittent, the timing of presentation can be variable.
Bilious or bile-stained vomiting should be treated as a potential surgical emergency.
Gastro-esophageal reflux (GER) is extremely common in infants, describe a classical presentation of it.
how is it different from GERD?
and typically presents in infants between 1-3 months of age.
characterized by frequent small volume regurgitation of a milky substance, irritability with feeds or when lying supine, or back arching with feeds. Many infants are asymptomatic.
Gastro-esophageal reflux is a normal physiologic process in infants and must be distinguished from gastro-esophageal reflux disease (GERD), which is associated with esophagitis, failure to thrive and recurrent aspiration.
what is intussusception and how does it normally present?
involves invagination of a portion of the small bowel into another portion of bowel (telescoping)
It is the most common cause of intestinal obstruction in children six to 36 months of age.
In addition to vomiting, the classic triad of features includes intermittent, progressive abdominal pain with screaming and drawing up of legs,
palpable sausage-like abdominal mass.
red currant jelly stools (late sign)
what are ‘red current jelly stools’ associated with?
intussusception
what 3 worrying features should you always ask about in a child presenting with vomiting, which will help to narrow down ddx?
bilious vs non bilious - is it green/yellow?
bloody/non bloody - red/brown
projectile/non projectile? - where does the sick go? hits the wall? - pyloric stenosis
First, it should be categorized as bilious or non-bilious. Bilious vomit has a greenish appearance due to the presence of bile and is indicative of obstruction distal to the ampulla of Vater, the opening of the common bile duct into the duodenum. Thus, determining whether vomit is bilious or non-bilious helps to localize GI problems within the GI tract.
Second, it should be categorized as bloody or non-bloody. Blood in the vomit indicates inflammation or damage to the GI mucosa and may indicate need for endoscopy to rule out acute upper GI bleed.
Third, the vomit should be identified as projectile or non-projectile, as projectile vomiting may point to a specific diagnosis – namely, pyloric stenosis. True expulsive vomiting should be distinguished!
run through the most common causes of vomiting based on the age of a child?
newborn
infancy
child
adolescent
The most common causes of vomiting in the neonatal period include gastroenteritis, malrotation, pyloric stenosis, TEF and necrotizing enterocolitis (esp if prem), duodenal atresia
In infancy, common causes are GERD, gastroenteritis, bowel obstruction, milk protein allergy and UTI.
In children, one must think of gastroenteritis, UTI, DKA, post-tussive vomiting and increased intracranial pressure.
In adolescents, consider gastroenteritis, appendicitis, DKA and increased intracranial pressure on the differential.
to help distinguish between infection causing vomiting or a non infective aetiology, one should ask about?
what infections might cause vomiting in children?
fevers
actual gastroenteritis
- pyelonephritis
- meningitis
what advice should be given to the parents of a baby with Gastro oesophageal reflux?
nurse upright where possible - positioning
encourage papoose slings
small but frequent feeds
add infant gaviscon to bottle fed babies
can get a powder that’s mixed with formula to thicken it or use a pre-thickened formula milk or change feeds
if these don’t work we can give you some drugs, such as antacids, H2 blocker or PPI
what types of children have an increased incidence of GORD?
cerebral palsy
chronic lung disease of prematurity
down syndrome
how do babies with GORD present?
The main sign of gastro-oesophageal reflux is frequent spitting up or regurgitation after feeds.
This is often accompanied by abdominal pain or general crankiness in the hours after feeding.
Over time, babies with reflux may not gain weight as expected (failure to thrive) and may have frequent chest infections due to aspirating (breathing in) stomach contents into the windpipe and lungs.
What is GORD caused by?
When is it common and when should it improve?
Gastro-oesophageal reflux is very common in the first few weeks and months of life, as the sphincter (ring of muscle) at the base of the oesophagus has not matured yet.
Many babies with reflux gradually improve as they grow, particularly when they start to eat more solid food and feed in an upright position in a high chair for instance (6-8 months).
If a child has severe gastro-oesophageal reflux which is not controlled with medication or is causing significant complications what can be done? and what tests would be done before this decision is made?
your doctor may recommend an operation called a fundoplication to prevent reflux.
Before reaching this decision, the severity of the child’s reflux will usually be assessed with:
pH impedance study (24 oesophageal probe)
upper GI contrast study
what medications can be used to treat reflux if conservative measures, such as thickening milk and repositioning fail?
infant gaviscon
ranitidine (H2 antagonist = less acid) - for screamers
domperidone (prokinetic = increased gastric emptying) - - for vomiters
how does gastroenteritis normally present in babies/children?
sudden change to more than 2 watery stools or 2 vomits a day +/- fever, abdominal pain
what most commonly causes gastroenteritis children/babies?
which cause can cause a life threatening illness?
MOST ARE VIRAL SO ABX DO NOT PLAY A PART IN THIS
viruses- rotavirus(less so now after vaccinations), adenovirus
less commonly bacterial - salmonella, campylobacter, e.coli 0157
ecoli 0157 have to worry about as it can cause HUS - haemolytic uraemic syndrome as it releases the shiga toxin
what tests should you do in suspected haemolytic uraemic syndrome and what will they show?
FBC and blood film
AND U+E
FBC will show low platelets and low haemoglobin
film will show fragmented red cells (schistocytes)
U+E will show acute renal failure
what is the pathophysiology in haemolytic uraemic syndrome?
ecoli 0157 releases shiga toxin
shiga toxin causes endothelial damage in microvasculature of renal circulation
activation of coagulation cascase and microvascular thrombosis in the renal syndrome
this causes
- platelet aggregation in kidney = consumption thrombocytopenia
- fibrin/platelet mesh causes partial occupation of the microcirculation = acute renal failure
- mesh shreds encirculating red cells giving fragmented red cells on film = microangiopathic haemolytic anaemia
how do you manage gastroenteritis?
most cases are self limiting and should be managed at home with oral fluid (diarolyte)
more severe cases leading to dehydration may need admission for rehydration with NG fluids or IV fluids
stool samples can be sent to help isolate the organism if required
when you see/feel an olive shaped mass under the right upper quadrant want condition are you thinking of?
pyloric stenosis
what investigations would you do for pyloric stenosis?
surgical emergency but also potential medical emergency
- test feed - observe feed, watch for hyper peristalsis, palpate for pyloric mass, witness projectile vomit
- cap gas - METABOLIC ALKALOSIS IS A MEDICAL EMERGENCY
- ultrasound- thickened and lengthened pyloric muscle (but if not seen it doesn’t rule it out because intraobserver differences)
U+E might show raised sodium, urea, creatinine (dehydrated) and low potassium and chloride (from vomiting)
