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
2
Q
Types of vomiting
A
- Vomiting with retching
- Projectile vomiting
- Bilious vomiting
- Effortless vomiting
- Haematemesis
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
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
5
Q
Effortless vomiting
A
- Commonly from GORD
- Self-limiting, resolves spontaneously
- Exceptions
- Cerebral palsy
- Progressive neurological problems
- Oesophageal atresia
- Generalised GI motility problems
6
Q
Pathogenesis of reflux in children
A
- More commonly in lying posture
- Feeds are usually liquid
- Alters with changes in diet and posture
7
Q
Presentation of good
A
- Vomiting
- Haematemesis
- Feeding problems
- Failure to thrive
- Apnoea
- Cough
- Wheeze
- Chest infection
- Sandifer’s syndrome → movement disorder
8
Q
Diagnosis of GORD
A
- History and examination
- Oesophageal pH study/ impedance monitoring
- Endoscopy
- Video fluoroscopy
- Barium swallow
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
10
Q
Feeding volumes in paediatrics
A
- Neonates → 150ml/kg/day
- Infants → 100ml/kg/day
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
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
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
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
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
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
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
18
Q
Osmotic vs secretory diarrhoea
A
- Osmotic
- Small volume
- Stops in response to fasting
- Secretory
- Large stool volume
- Continues despite fasting
19
Q
Fat malabsorption
A
- Pancreatic disease
- Lack of lipase → steatorrhea
- Classically in Cystic fibrosis
- Hepatobiliary disease
- Chronic liver disease
- Cholestasis
20
Q
Coeliac diseas e
A
- Gluten sensitive enteropathy
- Commonly causes malapsortion
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
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
23
Q
Pathological findings in coeliac disease
A
- Lymphocytic infiltration of surface epithelium
- Partila/ total villous atrophy
- Crypt hyperplasia
24
Q
Treatment of coeliac disease
A
- Gluten free diet for life → dietary advice
- Increased risk of rare small bowel lymphoma if untreated
25
Q
Liver function tests
A
- 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
Q
Liver function tests
A
- 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
Q
Tests to assess liver function
A
- Coagulation → prothrombin time and APTT
- Albumin
- Bilirubin
- Blood glucose
- Ammonia
27
Q
Presentation of liver disease in children
A
- Jaundice
- Incidental findings on blood test
- Signs and symptoms of chronic liver disease
- Growth failure
28
Q
Types of jaundice q
A
- Pre-hepatic
- Mostly unconjugated
- Haemolysis
- Intra-hepatic
- Mixed both conjugated and unconjugated
- Chronic liver disease
- Post-hepatic
- Cholestasis
- Mostly conjugated
- Obstructive process
29
Q
Types of jaundice q
A
- Pre-hepatic
- Mostly unconjugated
- Haemolysis
- Intra-hepatic
- Mixed both conjugated and unconjugated
- Chronic liver disease
- Post-hepatic
- Cholestasis
- Mostly conjugated
- Obstructive process
30
Q
Diagnosis of infant jaundice
A
- Understanding bilirubin metabolism → differentiate between unconjugated/ conjugated bilirubin and site of jaundice
- Age of onset
31
Q
Classification of jaundice by age
A
- 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
Q
Physiological jaundice
A
- Shorter RBC life span in infants (80-90 days)
- Relative polycythaemia
- Immaturity of liver function
- Causes more red cell breakdown
- Exclusively unconjugated jaundice
33
Q
Breast-milk jaundice
A
- Prolonged jaundice in breast-fed babies
- Unclear cause
34
Q
Kernicterus
A
- 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
Q
Kernicterus
A
- 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
Q
Treatment for unconjugated jaundice
A
- Phototherapy
- Visible light (not UV)
- Converts bilirubin into water soluble isomer (photoisomerisation)
- Dosage determined by charts
36
Q
Other causes of early/intermediate unconjugated infant jaundice
A
- 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
Q
Causes of prolonged infant jaundice
A
- Conjugated
- Anatomical obstruction (biliary tree)
- Neonatal hepatitis
- Un-conjugated
- Hypothyroidism
- Breast milk jaundice
38
Q
Important tests in prolonged jaundice
A
- Split bilirubin
- Differentiate between conjugated and unconjugated jaundice
- Conjugated jaundice is less of a concern
39
Q
Causes of biliary obstruction
A
- 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
Q
Most important assessment in prolonged infant jaundice
A
- Stool colour → always assess colour of stools
- Indicates whether it is post-hepatic, intrahepatic or pre-hepatic
41
Q
Biliary atresia
A
- 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
Q
Treatment of biliary atresia
A
- Kasai portoenterostomy
- Anastomosis of liver directly to small intestine
43
Q
Investigations for prolonged jaundice
A
- Split bilirubin
- Stool colour
- Ultrasound
- Liver biopsy
- Genetic testing
44
Q
Cause of neonatal hepatitis
A
- Alpha-1- antitrypsin deficiency
- Galactosaemia
- Tyrosinaemia
- Urea cycle defects
- Haemochromatossi
- Glycogen storage disorder
- Hypothyroidism
- Viral hepatitis
- Parenteral nutrition
45
Q
Definition of constipation
A
- Infrequent passage of stools
- Normal frequency → dependant on age, diet and genetics
46
Q
Signs and symptoms of constipation
A
- Poor appetite
- Irritable
- Lack of energy
- Abdominal pain or distension
- Withholding or straining
- Diarrhoea → liquid overflow
47
Q
What causes constipation
A
- Social
- Poor diet → sufficient fluid, excessive milk
- Potty training/ school toilet
- Physical
- Intercurrent illness
- Medications
- Psychological (secondary)
- Organic
48
Q
Cycle of constipation
A
- Pain or anal fissure
- Withholding stool
- Constipation
- Large hard stool
49
Q
Treatment of constipation
A
- 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
Q
Complications of chronic constipation
A
- Megarectum
51
Q
Treatment of severe constipation
A
- Empty impacted rectum
- Empty colon
- Maintain regular stool passage
- Slow weaning off treatment
- Ensure compliance
52
Q
Ulcerative colitis vs Crohn’s disease
A
- 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
Q
Diagnosis of IBD
A
- History and examination
- Intestinal symptoms
- Extra-intestinal symptoms
- Exclusion of infection → typhoid, dysentery
- Family history
- Growth and sexual development
- Nutritional status
54
Q
Extraintestinal manifestation of IBD
A
- Erythema nodosum
- Angular cheilitis
- Perinatal ulcer
55
Q
Investigations for IBD
A
- FBC and ESR
- Anaemia
- Thrombocytosis
- Raised ESR
- Biochemistry
- Stool calprotectin
- Raised CRP
- Low albumin → protein enteropathy
- Microbiology → stool pathogens
56
Q
Definitive diagnosis of IBD
A
- Radiology
- MRI
- Barium swallow
- Endoscopy
- Colonoscopy and upper GI endoscopy
- Mucosal biopsy
- Capsule enteroscopy
- Enteroscopy
57
Q
Aims of treatment in IBD
A
- Induce and maintain remission
- Correct nutritional deficiencies
- Maintain normal growth and development
