Paediatric - Gastroenterology Flashcards
GORD is caused by reflux through which sphincter
Lower oesophageal sphincter
Name some signs of problematic reflux in babies
And over 1 yo?
Chronic cough Hoarse cry Distress, crying or unsettled after feeding Reluctance to feed Pneumonia Poor weight gain
- Children over one year may experience similar symptoms to adults, with heartburn, acid regurgitation, retrosternal or epigastric pain, bloating and nocturnal cough
What could you advise to prevent reflux after feeding?
Small, frequent meals
Burping regularly to help milk settle
Not over-feeding
Keep the baby upright after feeding (i.e. not lying flat)
Name a risk factor for GORD
Premature birth.
Parental history of heartburn or acid regurgitation.
Obesity.
Hiatus hernia.
History of congenital diaphragmatic hernia (repaired) or congenital oesophageal atresia (repaired).
Neurodisability (such as cerebral palsy)
What symptoms might require same-day admission in a baby presenting with GORD
Haematemesis
Melaena.
Dysphagia.
What is Sandifer’s syndrome?
This is a rare condition causing brief episodes of abnormal movements associated with gastro-oesophageal reflux in infants. The infants are usually neurologically normal. The key features are:
Torticollis: forceful contraction of the neck muscles causing twisting of the neck
Dystonia: abnormal muscle contractions causing twisting movements, arching of the back or unusual postures
At what age is pyloric stenosis common?
2-8 weeks
Name some features of Infantile Pyloric Stenosis
- Onset of vomiting at 2-8 weeks of age (non-bilious, often projectile, increasing in frequency/intensity and usually 30-60 minutes after a feed, with the baby remaining hungry) (Slight haematemesis may occur.)
- Persistent hunger, weight loss, dehydration, lethargy, and infrequent or absent bowel movements may be seen. (Failure to Thrive)
- Stomach wall peristalsis may be visible.
- An enlarged pylorus, classically described as an ‘olive’, may be palpated in the right upper quadrant or epigastrium of the abdomen at the start of a feed
Name 2 investigations for Infantile Pyloric Stenosis
U+E, USS
What electrolyte imbalance might be seen on blood gas analysis of a baby vomiting due to pyloric stenosis?
blood gas analysis will show a hypochloric (low chloride) metabolic alkalosis as the baby is vomiting the hydrochloric acid from the stomach
Name some features of Acute Appendicitis
- Periumbilical or epigastric pain that worsens, and migrates to the right lower quadrant over 24–48 hours. It is typically aggravated by movement.
- Loss of appetite
- Low-grade fever, general malaise, and anorexia.
- Nausea, vomiting, and sometimes constipation or diarrhoea.
- Tenderness in the right lower quadrant on abdominal examination, which may be worse on coughing or hopping in children.
- Abdominal distension, guarding, rebound tenderness or percussion tenderness, or absent bowel sounds (which may all suggest peritonitis).
- A palpable abdominal mass (which may suggest an appendix mass or abscess).
- Rovsing’s sign + rebound and percussion tenderness
- Note: appendicitis may present atypically, particularly in the very young, elderly, and in pregnancy, and the anatomical position of the appendix may vary resulting in different clinical presentations.
What are some key differentials to exclude with Appendicitis?
- Ectopic (serum bHCG - pregnancy test)
- Ovarian cysts (rupture/torsion?)
- Meckel’s diverticulum (malformation of distal ileum, which can cause intussusception/volvulus)
- Mesenteric adenitis (inflamed abdominal lymph nodes, due to URTI?)
- Appendix mass (omentum surrounds and sticks to the inflamed appendix)
At what age is Intussusception common?
+sex?
It typically occurs in infants 6 months to 2 years and is more common in boys.
Name a condition which is associated with Intussusception
- Concurrent viral illness
- Henoch-Schonlein purpura
- Cystic fibrosis
- Intestinal polyps
- Meckel diverticulum
How might Intussusception present?
- Severe, colicky abdominal pain
- Pale, lethargic and unwell child
- “Redcurrant jelly stool”
- Right upper quadrant mass on palpation. This is described as “sausage-shaped”
- Vomiting
- Intestinal obstruction
(The typical child in the exam will have viral URTI preceding the illness + intestinal obstruction features (vomiting, absolute constipation and abdominal distention). Ultrasound is the initial investigation of choice.
Meckel’s Diverticulum is caused due to vestigial remnant of what duct?
the vitellointestinal duct
Most cases of Meckel’s Diverticulum are asymptomatic
How might the symptomatic patient present?
- Haemorrhage
- Intestinal Obstruction
- Diverticulitis
- Perforation
- Umbilical anomaly
- Neoplasm
Name a cause of intestinal obstruction
- Meconium ileus
- Hirschsprung’s disease
- Oesophageal atresia
- Duodenal atresia
- Intussusception
- Imperforate anus
- Malrotation of the intestines with a volvulus
- Strangulated hernia
How might intestinal obstruction present in a child?
- Persistent vomiting. This may be bilious, containing bright green bile.
- Abdominal pain and distention
- Failure to pass stools or wind
- Abnormal bowel sounds. These can be high pitched and “tinkling” early in the obstruction and absent later.
What is the initial investigation for intestinal obstruction?
Abdominal X-ray
IBS features
- Abdominal pain which is either related to defecation, and/or associated with altered stool frequency (increased or decreased), and altered stool form or appearance (hard, lumpy, loose, or watery)
- Passage of rectal mucus, and
- Symptoms worsened by eating.
- Abdominal bloating (more common in women than men), distension, or hardness.
- Altered stool passage (straining, urgency, or incomplete evacuation).
What tests might be done for IBS?
- Full blood count (FBC) - to rule out lack of iron in the blood (anaemia), which is associated with various gut (bowel) disorders.
- Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) - which can show if there is inflammation in the body (which does not occur with IBS).
- A blood test for coeliac disease.
- In women, a blood test to rule out cancer of the ovary, called CA 125.
- A stool test to look for a protein called faecal calprotectin. This may be present if you have Crohn’s disease or ulcerative colitis, but is not present in IBS. A stool test may also be used to check whether you have any bleeding from your bowel.
Crohn’s VS UC
Crohn’s (crows NESTS)
N – No blood or mucus (these are less common in Crohns.)
E – Entire GI tract
S – “Skip lesions” on endoscopy
T – Terminal ileum most affected and Transmural (full thickness) inflammation
S – Smoking is a risk factor (don’t set the nest on fire)
(+ Cobblestone appearance)
Ulcerative Colitis (remember U – C – CLOSEUP)
C – Continuous inflammation L – Limited to colon and rectum O – Only superficial mucosa affected S – Smoking is protective E – Excrete blood and mucus U – Use aminosalicylates P – Primary sclerosing cholangitis
What tests are done for IBD
- Blood tests for anaemia, infection, thyroid, kidney and liver function. A raised CRP indicates active inflammation.
- Faecal calprotectin is released by the intestines when inflamed. It is a useful screening test and is more than 90% sensitive and specific for IBD in adults.
- Endoscopy (OGD and colonoscopy) with biopsy is the gold standard investigation for diagnosis of IBD.
- Imaging with ultrasound, CT and MRI can be used to look for complications such as fistulas, abscesses and strictures.
Management of Crohn’s: Inducing remission + Maintaining remission
Inducing Remission
- First line are steroids (e.g. oral prednisolone or IV hydrocortisone).
- If steroids alone don’t work, consider adding immunosuppressant (Azathioprine, Methotrexate, Infliximab)
Maintaining Remission
- First line (Azathioprine, Mercaptopurine)
- Alternatives (Methotrexate, Infliximab)
Management of UC: Inducing remission + Maintaining remission
Inducing Remission
- Mild to moderate disease
First line: aminosalicylate (e.g. mesalazine oral or rectal)
Second line: corticosteroids (e.g. prednisolone)
- Severe disease
First line: IV corticosteroids (e.g. hydrocortisone)
Second line: IV ciclosporin
Maintaining Remission
- Aminosalicylate (e.g. mesalazine oral or rectal)
- Azathioprine
What must you do in a hospital ward or paediatric assessment unit when a patient with Gastroenteritis is admitted?
Isolate them, as they can easily spread it to other patients
What are 2 common viral causes of Gastroenteritis?
Rotavirus + Norovirus
What are some bacterial causes of Gastroenteritis?
E. coli, Campylobacter jejune, Shigella, Salmonella, Bacillus Cereus (leftover rice!), Giardiasis, S. Aureus
What are the diagnostic criteria for Constipation called?
The Rome IV diagnostic criteria for constipation include spontaneous bowel movements occurring less than three times a week
What is a post-gastroenteritis complication?
Lactose intolerance
Irritable bowel syndrome
Reactive arthritis
Guillain–Barré syndrome
What is Encopresis?
Faecal incontinence
Which antibodies will rise with more active Coeliac disease and may disappear with effective treatment
(+ associated with which Ig?)
anti-tissue transglutaminase (anti-TTG) and anti-endomysial (anti-EMA)
(Both IgA! Some patients have an IgA deficiency. When you test for these antibodies, it is important to test for total Immunoglobulin A levels because if total IgA is low the coeliac test will be negative even when they have the condition. In this circumstance you can test for the IgG version of the anti-TTG or anti-EMA antibodies or do an endoscopy with biopsies)
Also - Deaminated gliadin peptides antibodies (anti-DGPs)
Name some symptoms of Coeliac Disease
+neuro Sx?
- Failure to thrive in young children
- Diarrhoea
- Fatigue
- Weight loss
- Mouth ulcers
- Anaemia secondary to iron, B12 or folate deficiency
- Dermatitis herpetiformis is an itchy blistering skin rash that typically appears on the abdomen
Rare neurological symptoms:
- Peripheral neuropathy
- Cerebellar ataxia
- Epilepsy
Name some conditions that Coeliac Disease is associated with
- Type 1 diabetes
- Thyroid disease
- Autoimmune hepatitis
- Primary biliary cirrhosis
- Primary sclerosing cholangitis
- Down’s syndrome
Endoscopy and intestinal biopsy show what in Coeliac disease?
“Crypt hypertrophy”
“Villous atrophy”
What are the 2 genetic associations for Coeliac disease?
HLA-DQ2 gene (90%)
HLA-DQ8 gene
The key pathophysiology in Hirschsprung’s disease is?
absence of parasympathetic ganglion cells
What are 2 investigations for Hirschsprungs?
Abdominal xray can be helpful in diagnosing intestinal obstruction and demonstrating features of HAEC.
Rectal biopsy is used to confirm the diagnosis. The bowel histology will demonstrates an absence of ganglionic cells.
Toddler’s diarrhoea is most common at what age?
It mainly affects children between the ages of 1 and 5 years and is more common in boys
What are the features of Toddler’s diarrhoea?
- chronic nonspecific diarrhoea
- stools are often more smelly and pale than usual
- otherwise well, grows normally, plays normally and is usually not bothered about the diarrhoea
A serious condition:
A premature infant (30-week gestation) presents with distended and tense abdomen. She is passing blood and mucus per rectum, and she is also manifesting signs of sepsis.
Necrotising enterocolitis
- 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
This condition presents during the first days of life with gross abdominal distension and bilious vomiting. X-ray of the abdomen shows distended coils of bowel and typical mottled ground glass appearance. Fluid levels are scarce as the meconium is abnormally bulky and viscid
Meconium Ileus
- Usually delayed passage of meconium and abdominal distension
- 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
Where is Thiamine absorbed?
Duodenum
What is the initial treatment of Hirschprung’s Disease?
Initial: rectal washouts/bowel irrigation
definitive management: surgery to affected segment of the colon (Swenson procedure)
Ultrasound of Intussusception shows what characteristic feature?
A target-like mass
What is the surgical management of pyloric stenosis?
Ramstedt pyloromyotomy
What is the number one cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years.
Meckel’s Diverticulum
Prophylactic for abdominal migraine?
- Pizotifen (serotonin agonist) is the main one. Withdrawn slowly when stopping as it is associated with withdrawal symptoms such as depression, anxiety, poor sleep and tremor.
- Propranolol, a non-selective beta blocker
- Cyproheptadine, an antihistamine
- Flunarazine, a calcium channel blocker
What is first line laxative for idiopathic constipation?
Movicol (Osmotic laxative + contains Macrogol)
