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Paediatric gastroenterology Flashcards

1
Q

Triggers of vomiting

A
  • Infection
  • Enteric pathogen
  • Inner ear stimuli → motion sickness
  • Head injury/ raised ICP
  • Metabolic derangement/ chemotherapy
  • Visual/ olfactory stimuli/ fear
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2
Q

Types of vomiting

A
  • Vomiting with retching
  • Projectile vomiting
  • Bilious vomiting
  • Effortless vomiting
  • Haematemesis
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3
Q

Commonest causes fo vomiting

A
  • Infants
    • GOR
    • Cow’s milk allergy
    • Infection
    • Intestinal obstruction
  • Children
    • Gastroenteritis
    • Infection
    • Appendicitis
    • Intestinal obstruction
    • Raised ICP
    • Coeliac disease
  • Young adults
    • Gastroenteritis
    • Infection
    • H.pylori disease
    • Appendicitis
    • Raised ICP
    • DKA
    • Cyclical vomiting syndrome
    • Bulimia
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4
Q

Pyloric stenosis

A
  • Babies 4-12 weeks
  • Boys > girls
  • Projectile non-bilious vomiting
  • Weight loss
  • Dehydration +/- shock
  • Electrolyte disturbance
    • Metabolic alkalosis
    • Hypochloraemia
    • Hypokalaemia
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5
Q

Effortless vomiting

A
  • Commonly from GORD
  • Self-limiting, resolves spontaneously
  • Exceptions
    • Cerebral palsy
    • Progressive neurological problems
    • Oesophageal atresia
    • Generalised GI motility problems
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6
Q

Pathogenesis of reflux in children

A
  • More commonly in lying posture
  • Feeds are usually liquid
  • Alters with changes in diet and posture
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7
Q

Presentation of good

A
  • Vomiting
  • Haematemesis
  • Feeding problems
  • Failure to thrive
  • Apnoea
  • Cough
  • Wheeze
  • Chest infection
  • Sandifer’s syndrome → movement disorder
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8
Q

Diagnosis of GORD

A
  • History and examination
  • Oesophageal pH study/ impedance monitoring
  • Endoscopy
  • Video fluoroscopy
  • Barium swallow
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9
Q

Treatment of GORD

A
  • Feeding advice
    • Feed thickeners fo liquids
    • Feed volumes
    • Behaviours changes
    • Feeding position
      • Nutritional support
    • High calorie feed
    • Exclusion diet
    • NG tube
  • Medical treatment
    • Prokinetic drugs
    • Acid suppressing drugs
  • Surgery → last resort
    • Nissen fundoplication
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10
Q

Feeding volumes in paediatrics

A
  • Neonates → 150ml/kg/day
  • Infants → 100ml/kg/day
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11
Q

Indication for surgery in GORD

A
  • Failure of all other avenues
  • Persistent
    • Failure to thrive
    • Aspiration
    • Oesophagitis
  • Not indicated in vomiting without complications
  • Nissen’s fundoplication
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12
Q

Bilious vomiting

A
  • Red flag
  • Intestinal obstruction until proven
  • Causes
    • Intestinal atresia
    • Malrotation
    • Intesussception
    • Ileus
    • Crohn’s disease without strictures
  • Investigations
    • Abdo x-ray
    • Consider contract meal
    • Exploratory laparotomy
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13
Q

Definition of chronic diarrhoea

A
  • 4 or more stools per day for more than 4 weeks
  • <1 week → acute diarrhoea
  • 2-4 weeks → persistent diarrhoea
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14
Q

Causes of chronic diarrhoea

A
  • Motility disturbances
    • Toddlers diarrhoea
    • IBS
  • Active secretion
    • Acute infection diarrhoea
    • Inflammatory bowel disease
  • Malabsorption → osmotic
    • Food allergy
    • Coeliac disease
    • Cystic fibrosis
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15
Q

Osmotic diarrhoea

A
  • Net water movement into bowel to equalise osmotic equilibrium
  • Feature of malabsorption
    • Enzyme defect → lactase deficiency
    • Transport defect → Glucose-galactose transporter defect
  • Also mechanism of lactulose/ movicol → osmotic laxatives
  • Remission with removal of causative agent
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16
Q

Secretory diarrhoea

A
  • Most common → E.coli associated enterotoxin
  • Intestinal fluid secretion due to active Cl- secretion via CFTR
  • Lose a lot of fluid
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17
Q

Clinical approach to chronic diarrhoea

A
  • History
    • Age of onset
    • Abrupt/ gradual
    • Family history
    • Travel history/ local outbreak
    • Nocturnal defection → always pathological
  • Growth and weight of child
  • Faecal analysis → culture, appearance
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18
Q

Osmotic vs secretory diarrhoea

A
  • Osmotic
    • Small volume
    • Stops in response to fasting
  • Secretory
    • Large stool volume
    • Continues despite fasting
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19
Q

Fat malabsorption

A
  • Pancreatic disease
    • Lack of lipase → steatorrhea
    • Classically in Cystic fibrosis
  • Hepatobiliary disease
    • Chronic liver disease
    • Cholestasis
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20
Q

Coeliac diseas e

A
  • Gluten sensitive enteropathy
  • Commonly causes malapsortion
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21
Q

Presentation of coeliac disease

A
  • Abdominal bloatedness
  • Diarrhoea
  • Failure to thrive
  • Short stature
  • Constipation
  • Tiredness
  • Dermatitis herpatiformis
  • Commonly occurs with: other autoimmune conditions, first degree relatives, insulin-dependant DM
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22
Q

Screening for coeliac disease

A
  • Serological screen
    • Anti-tissue transglutaminase antibodies (high sensitivity)
    • Anti-endomysial
    • Serum IgA → high in malignancy, infection, autoimmune condition s
  • Duodenal biopsy → gold standard
  • Genetic testing → HLA DQ2, DQ8
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23
Q

Pathological findings in coeliac disease

A
  • Lymphocytic infiltration of surface epithelium
  • Partila/ total villous atrophy
  • Crypt hyperplasia
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24
Q

Treatment of coeliac disease

A
  • Gluten free diet for life → dietary advice
  • Increased risk of rare small bowel lymphoma if untreated
25
Liver function tests
* Bilirubin * Total * Split → direct (conjugated), indirect (unconjugated) * ALT/AST (alanine aminotransferase/ aspartate aminotransferase) → elevated in hepatocellular damage (hepatitis) * Alkaline phosphatase → elevated in biliary disease * Gamma glutamyl transverse (GGT)
25
Liver function tests
* Bilirubin * Total * Split → direct (conjugated), indirect (unconjugated) * ALT/AST (alanine aminotransferase/ aspartate aminotransferase) → elevated in hepatocellular damage (hepatitis) * Alkaline phosphatase → elevated in biliary disease * Gamma glutamyl transverse (GGT)
26
Tests to assess liver function
* Coagulation → prothrombin time and APTT * Albumin * Bilirubin * Blood glucose * Ammonia
27
Presentation of liver disease in children
* Jaundice * Incidental findings on blood test * Signs and symptoms of chronic liver disease * Growth failure
28
Types of jaundice q
* Pre-hepatic * Mostly unconjugated * Haemolysis * Intra-hepatic * Mixed both conjugated and unconjugated * Chronic liver disease * Post-hepatic * Cholestasis * Mostly conjugated * Obstructive process
29
Types of jaundice q
* Pre-hepatic * Mostly unconjugated * Haemolysis * Intra-hepatic * Mixed both conjugated and unconjugated * Chronic liver disease * Post-hepatic * Cholestasis * Mostly conjugated * Obstructive process
30
Diagnosis of infant jaundice
* Understanding bilirubin metabolism → differentiate between unconjugated/ conjugated bilirubin and site of jaundice * Age of onset
31
Classification of jaundice by age
* Early (\>24 hours) * Always pathological * Causes: haemolytic, sepsis * Intermediate (24h-2 weeks) * Causes: physiological, breast milk, sepsis, haemolytic * Prolonged (\>2 weeks) * Causes: extra hepatic obstruction, neonatal hepatitis, hypothyroidism, breast milk
32
Physiological jaundice
* Shorter RBC life span in infants (80-90 days) * Relative polycythaemia * Immaturity of liver function * Causes more red cell breakdown * Exclusively unconjugated jaundice
33
Breast-milk jaundice
* Prolonged jaundice in breast-fed babies * Unclear cause
34
Kernicterus
* Complication of hyperbilirubinaemia * Unconjugated bilirubin is fat-soluble so crosses BBB and deposits in break * Early signs → encephalopathy, poor feeding, lethargy * Late consequences → severe chorathetoid cerebral palsy, learning difficulties, sensorineural deafness
34
Kernicterus
* Complication of hyperbilirubinaemia * Unconjugated bilirubin is fat-soluble so crosses BBB and deposits in break * Early signs → encephalopathy, poor feeding, lethargy * Late consequences → severe chorathetoid cerebral palsy, learning difficulties, sensorineural deafness
35
Treatment for unconjugated jaundice
* Phototherapy * Visible light (not UV) * Converts bilirubin into water soluble isomer (photoisomerisation) * Dosage determined by charts
36
Other causes of early/intermediate unconjugated infant jaundice
* Sepsis * Haemolysis * ABO incompatibility * Rhesus disease * Bruising/ cephalhaematoma * Red cell membrane defects (spherocytosis) * Red cell enzyme defect (G6PD) * Abnormal conjugation * Gilbert's disease - come * Crigler-Najjar syndrome - rare
37
Causes of prolonged infant jaundice
* Conjugated * Anatomical obstruction (biliary tree) * Neonatal hepatitis * Un-conjugated * Hypothyroidism * Breast milk jaundice
38
Important tests in prolonged jaundice
* Split bilirubin * Differentiate between conjugated and unconjugated jaundice * Conjugated jaundice is less of a concern
39
Causes of biliary obstruction
* Biliary atresia * Post-hepatic * Conjugated jaundice * Pale stools * Choledochal cuts * Post-hepatic * Conjugated jaundice * Pale stools * Alagille syndrome * Intrahepatic cholestasis * Dysmorphism * Congenital heart disease
40
Most important assessment in prolonged infant jaundice
* Stool colour → always assess colour of stools * Indicates whether it is post-hepatic, intrahepatic or pre-hepatic
41
Biliary atresia
* Congenital fibro-inlammatory disease of bile ducts → destruction of extrehepatic bile ducts * Distal to proximal pattern of spread * Causes prolonged conjugated jaundice * Presentation → pale stools, dark urine * Progresses to liver failure if unidentified and untreated * Commonest indication for paediatric liver transplantation
42
Treatment of biliary atresia
* Kasai portoenterostomy * Anastomosis of liver directly to small intestine
43
Investigations for prolonged jaundice
* Split bilirubin * Stool colour * Ultrasound * Liver biopsy * Genetic testing
44
Cause of neonatal hepatitis
* Alpha-1- antitrypsin deficiency * Galactosaemia * Tyrosinaemia * Urea cycle defects * Haemochromatossi * Glycogen storage disorder * Hypothyroidism * Viral hepatitis * Parenteral nutrition
45
Definition of constipation
* Infrequent passage of stools * Normal frequency → dependant on age, diet and genetics
46
Signs and symptoms of constipation
* Poor appetite * Irritable * Lack of energy * Abdominal pain or distension * Withholding or straining * Diarrhoea → liquid overflow
47
What causes constipation
* Social * Poor diet → sufficient fluid, excessive milk * Potty training/ school toilet * Physical * Intercurrent illness * Medications * Psychological (secondary) * Organic
48
Cycle of constipation
1. Pain or anal fissure 2. Withholding stool 3. Constipation 4. Large hard stool
49
Treatment of constipation
* Dietary changes → increased fibre, fruit, vegetables, fluid, reduce milk * Reduce aversive factors * Correct height * not cold * Soften stool and remove pain * Rewarding good behaviour * Soften and stimulate stool * Osmotic laxatives * Stimulant laxative * Isotonic laxatives
50
Complications of chronic constipation
* Megarectum
51
Treatment of severe constipation
* Empty impacted rectum * Empty colon * Maintain regular stool passage * Slow weaning off treatment * Ensure compliance
52
Ulcerative colitis vs Crohn's disease
* Ulcerative colitis presents heavy diarrhoea and rectal bleeding * Crohn's disease presents with moderate diarrhoea and rectal bleeding but also weight loss and growth failure
53
Diagnosis of IBD
* History and examination * Intestinal symptoms * Extra-intestinal symptoms * Exclusion of infection → typhoid, dysentery * Family history * Growth and sexual development * Nutritional status
54
Extraintestinal manifestation of IBD
* Erythema nodosum * Angular cheilitis * Perinatal ulcer
55
Investigations for IBD
* FBC and ESR * Anaemia * Thrombocytosis * Raised ESR * Biochemistry * Stool calprotectin * Raised CRP * Low albumin → protein enteropathy * Microbiology → stool pathogens
56
Definitive diagnosis of IBD
* Radiology * MRI * Barium swallow * Endoscopy * Colonoscopy and upper GI endoscopy * Mucosal biopsy * Capsule enteroscopy * Enteroscopy
57
Aims of treatment in IBD
* Induce and maintain remission * Correct nutritional deficiencies * Maintain normal growth and development

Paediatrics (10 decks)

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