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Paediatrics > Paediatric gastroenterology > Flashcards

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
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
  1. Pain or anal fissure
  2. Withholding stool
  3. Constipation
  4. 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

Paediatrics (10 decks)

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