Paediatric Gastroenterology Flashcards
Red flags for abdominal pain
Persistent or bilous vomiting Severe chronic diarrhoea Fever Rectal bleeding Weight loss or failure to thrive Dysphagia Nocturnal pain Abdominal tenderness
Abdominal migraine features
Migraine associated with central abdominal pain lasting more than 1 hour
May have:
- nausea and vomiting
- anorexia and pallor
- photophobia
- aura
Management of abdominal migraines
- low stimulus environment - dark, quiet room
- paracetamol or NSAIDs
- Sumatriptans
Management of recurrent abdominal migraines
Prophylaxis - propanolol or pizotifen (serotonin agonist)
Secondary causes of constipation
Hirschprung’s disease
Cystic fibrosis
Hypothyroidism
Intususseption
Constipation history
- Frequency - normal vs now - less than 3 per week
- consistency
- blood or mucous in stool
- abdominal pain
- passed meconium
- straining
- diet and hydration
Red flags for constipation
Not passing meconium within 48 bours of birth
Neurological signs/ symptoms in lower limbs
Vomiting
Ribbon stool - anal stenosis
Failure to thrive
Acute severe abdo pain and bloating
Management of constipation
- increase fibre in the diet
- increase hydration
- increase physical activity
- movicol first line
- praise toilet visits
Causes of reflux
Physiological GORD CMPA Overfeeding Pyloric stenosis - non bilous Intersusseption - bilous vomiting Intestinal obstruction UTI Appendicitis
Signs of secondary reflux
Chronic cough Hoarse cry Distress after feeding Reluctance to feed Pneumonia Failure to thrive Dehydration - not wetting nappies
Red flags for reflux
Not keeping down any food - pyloric stenosis Projectile fomiting - pyloric stenosis Bilous - intestinal obstruction Haematemesis or maleana - peptic ulcer Abdominal distension - obstruction Reduced consciousness - meningitis Resp symptoms - aspiration Blood in stools - CMPA or gastroenteritis Rash - CMPA
Reflux advice
Small frequent meals
Burping regularly
Not over feeding
Keep baby upright after feeding
Management of reflux
Gaviscon
Thickened milk or specific formulas
PPI and omeprazole
Sandifer’s syndrome
Condition causing brief episodes of abnormal movements associated with reflux
- torticollis - forceful contraction of the neck muscles causing twisting
- dystonia - twisting and arching of the back or unusual postures
Pathophysiology of pyloric stenosis
Hypertrophy of the pylorus causing stenosis
After feeding, there is powerful peristalsis which causes projectile vomiting
Presentation of pyloric stenosis
Projectile vomiting
Failure to thrive
Olive like mass on abdo examination
Blood gas result for pyloric stenosis
Hypochloric hypokalaemic metabolic alkalosis
Investigations for pyloric stenosis
USS abdomen
Treatment of pyloric stenosis
Laparoscopic pyloromyotomy - Ramstedt’s operation
Gastroenteritis pathophysiology
Inflammation of the stomach and intestines commonly due to a viral infection
Gastroenteritis presentation
Nausea Vomiting Diarrhoea Dehydration Abdominal cramps
Causative organisms of gastroenteritis and method of infection
Rotavirus
Norovirus
E.coli
Campylobacter jejuni - travellers diarrhoea, unpasterised milk
Shigella - faecal contamination
Salmonella - raw eggs and poultry
Bacillus cereus - uncooked food - fried rice
Yersinia enterocolitica - pigs, rats and rabbits
Giardiasis (parasite)
Why should antibiotics be avoided in gastroenteritis caused by E.Coli?
E.Coli produces shiga toxin which can cause haemolytic ureamic syndrome. Antibiotics can increase the risk of HUS
Which bacterial cause of gastroenteritis causes lymphadenopathy
Yersinia enterocolitica - mesenteric lymphadenitis can mimic appendicitis
Management of gastroenteritis
Good hygiene
Isolation
Stay of school for 48 hours after symptoms have resolved
Hydration - fluid challenge and dioralyte
Antibiotics - may not be required
Investigations of gastroenteritis
Stool sample - microscopy, culture and sensitivity
Coeliac disease pathophysiology
Autoimmune reaction to gliadin factor present in gluten which targets epithelial cells of the intestines and causes atrophy
Investigations for coeliac disease
Remain on gluten diet:
- Bloods - Anti TTG and anti endomysial A antibodies
- endoscopy and biopsy - crypt hypertrophy and villous atrophy
- IgA levels - rule out IgA deficiency
Conditions associated with Coeliacs disease
Type 1 diabetes Thyroid disease Autoimmune hepatitis Primary biliary cirrhosis Primary sclerosing cholangitis Down’s syndrome Dermatitis herpetiformis
Presentation of coeliacs disease
Failure to thrive Abdominal distention Diarrhoea Fatigue Weight loss Mouth ulcers Anaemia - B12 deficiency Dermatitis herpetiforms
Genetic associations for coeliacs disease
HLA - DQ2
HLA - DQ8
Complications of untreated coeliacs disease
Vitamin deficiency - vit B12 Anaemia Osteoporosis Ulcerative jejunitis Non hodgkins lymphoma Small bowel adenocarcinoma Enteropathy associated T cell lymphoma (EATL)
Treatment of coeliacs disease
Lifelong gluten free diet
Features of Crohns disease
- entire GI tract can be affected
- skip lesions
- terminal ileum most affected and transmural inflammation - strictures and fistulas
- smoking exacerbates condition
Features of ulcerative colitis
- continuous inflammation
- rectum always involved
- superficial mucosa affected
- smoking is protective
- blood and mucous in stools
- associated with primary sclerosing cholangitis
Presentation of inflammatory bowel disease
Abdominal pain
Diarrhoea
Weight loss
Anaemia
Extra intestinal manifestations of inflammatpry bowel disease
Finger clubbing Erythema nodosum Pyoderma gangrenosum Iritis and episcleritis Inflammatory arthritis
Investigations for inflammtory bowel disease
Bloods - FBC (anaemia), TFTs, LFTs, U+Es
Faecal calprotectin
Endoscopy and biopsy
CT abdomen
General management of inflammatory bowel disease
MDT
Monitor growth and pubertal development
Inducing remission in Crohns
- Steroids - oral prednisolone or IV hydrocortisone
- Add azathioprine, mercaptopurine or methotrexate
- Infliximab
Maintaining remission in Crohns
- Azathioprine or mecaptopurine
- Methotrexate
- Infliximab
- Surgical resection of the terminal ileum
Inducing remission in ulcerative colitis
Mild to moderate - aminosalicylate e.g. mesalazine or 2nd line - prednisolone
Severe - IV hydrocortisone or IV ciclosporin
Maintaining remission in ulcerative colitis
- Aminosalicylates - mesalazine
- Azothioprine
- Mercaptopurine
- Panproctocolectomy
Pathophysiology of Hirschsprung’s disease
Absence of the parasympathetic ganglion cells in the form of myenteric plexus nerve cells in the distal portion of the bowel and rectum therefore lack of peristalsis
Total colonic aganglionosis
Entire colon lacks parasympathetic ganglion cells
Conditions associated with Hirschsprung’s disease
Downs syndrome
Neurofibromatosis
Multiple endocrine neoplasia type II
Presentation of Hirschsprungs disease
Delay in passing meconium - more than 24 hours Chronic constipation since birth Abdominal pain and distention Vomiting Failure to thrive
Hirschsprung associated enterocolitis
Inflammation and obstruction associated with hirschsprungs disease causing fever and features of sepsis
Can cause toxic megacolon and perforation
Requires urgent abx, fluid resuscitation and decompression
Investigations for hirschsprungs disease
Rectal biopsy
Abdominal xray
Management of hirschsprungs disease
Fluid resuscitation
NGT
IV antibiotics are required if there is HAEC
Surgical removal of the aganglionic section of the bowel
Intussusception pathophysiology
Bowel invaginates into itself, narrowing the lumen of the bowel and causes obstruction
Who does intussusception commonly present in
Infants 6 months - 2 years old boys
Conditions associated with intussusception
Concurrent viral illness Henoch Schonlein purpura Cystic fibrosis Intestinal polyps Meckel diverticulum
Presentation of intussusception
Severe colicky abdominal pain Pale, lethargic and unwell child Redcurrant jelly stool Sausage shaped mass in right upper quadrant Vomiting Intestinal obstruction
Investigations for intussusception
Abdominal USS
Management of intussusception
Therapeutic enemas - contrast, water, air
Surgical reduction
Complications of intussusception
Obstruction
Gangrenous bowel
Perforation
Death
Pathophysiology of appendicitis
Inflammation of the appendix caused by infection or impacted faecolith
Peak incidence of appendicitis
Between the ages of 10 - 20 years old
Presentation of appenditis
RIF pain and tenderness
Fever
Nausea and vomiting
Loss of apetite
Rovsings sign
Guarding
Rebound tenderness
Investigations for appendicitis
Bloods - FBC, CRP
Abdominal USS
If symptomatic but investigations are negative - diagnostic laparoscopy
Management of appendicitis
Emergency admission
Appendicectomy
