Paediatric gastroenterology Flashcards
What is biliary atresia?
a congenital condition where a section of the bile duct is either narrowed or absent
What does biliary atresia result in?
cholestasis
What does biliary atresia prevent the excretion of?
Conjugated bilirubin
When should you suspect biliary atresia?
babies with a persistent jaundice, lasting more than 14 days in term babies and 21 days in premature babies
What is the initial investigation for biliary atresia?
Conjugated and unconjugated bilirubin
What is the management for biliary atresia?
Kasai portoenterostomy surgery
What are the 4 surgical causes of abdominal pain?
Appendicitis, Intussuscpetion, bowel obstruction and testicular torsion
What are the red flags for abdominal pain?
Persistent or bilious vomiting
Severe chronic diarrhoea
Fever
Rectal bleeding
Weight loss or faltering growth
Dysphagia (difficulty swallowing)
Nighttime pain
Abdominal tenderness
What can anaemia in abdominal pain suggest?
IBD or coeliac disease
What can raised inflammatory markers in abdominal pain suggest?
IBD
What antibodies suggest coeliac disease?
anti-TTG or anti-EMA
What does raised faecal calprotectin indicate?
IBD
What is the most common cause of constipation in children?
Idiopathic constipation
What is encopresis?
Faecal incontinence
What are some rarer causes of encopresis?
Spina bifida, Hirschprung’s disease, cerebral palsy, learning difficulties, abuse, psychological stress
What are secondary causes of constipation?
Hirschprung’s disease, cystic fibrosis, hypothyroidism, spinal cord lesions, sexual abuse, intestinal obstruction, anal stenosis, cow milk intolerance
What are the red flags of constipation?
Not passing meconium within 48 hours of birth
Neurological signs or symptoms, particularly in the lower limbs
Vomiting
Ribbon stool
Abnormal anus
Abnormal lower back or buttocks
Failure to thrive
Acute severe abdominal pain and bloating
What is the red flag condition with constipation and not passing meconium within 48 hours of birth?
cystic fibrosis or Hirschsprung’s disease
What is the red flag condition with constipation and neurological signs or symptoms, particularly in the lower limbs?
cerebral palsy or spinal cord lesion
What is the red flag condition with constipation and vomiting?
intestinal obstruction or Hirschsprung’s disease
What is the red flag condition with constipation and ribbon stool?
anal stenosis
What is the red flag condition with constipation and abnormal anus?
anal stenosis, inflammatory bowel disease or sexual abuse
What is the red flag condition with constipation and abnormal lower back or buttocks?
spina bifida, spinal cord lesion or sacral agenesis
What is the red flag condition with constipation and failure to thrive?
coeliac disease, hypothyroidism or safeguarding
What is the red flag condition with constipation and acute severe abdominal pain and bloating?
obstruction or intussusception
What are the complications of constipation?
Pain
Reduced sensation
Anal fissures
Haemorrhoids
Overflow and soiling
Psychosocial morbidity
What is the first line laxative for constipation?
Movicol
Why do babies often get GORD?
Immaturity of the lower oesophageal sphincter, allowing stomach contents to easily reflux into the oesophagus.
90% of young children stop having GORD by what age?
1 year
What are the causes of vomiting in children?
Overfeeding
Gastro-oesophageal reflux
Pyloric stenosis (projective vomiting)
Gastritis or gastroenteritis
Appendicitis
Infections such as UTI, tonsillitis or meningitis
Intestinal obstruction
Bulimia
What are the red flags or
Not keeping down any feed
Projectile or forceful vomiting
Bile stained vomit
Haematemesis or melaena
Abdominal distention
Reduced consciousness, bulging fontanelle or neurological signs
Respiratory symptoms
Blood in the stools
Signs of infection
Rash, angioedema and other signs of allergy
Apnoeas
What red flag condition might GORD and not keeping down any feed suggest?
pyloric stenosis or intestinal obstruction
What red flag condition might GORD and projectile or forceful vomit suggest?
pyloric stenosis or intestinal obstruction
What red flag condition might GORD and not keeping down any feed suggest?bile stained vomit suggest?
intestinal obstruction
What red flag condition might GORD and haematemesis or melaena suggest?
peptic ulcer, oesophagitis or varices
What red flag condition might GORD and abdominal distention suggest?
intestinal obstruction
What red flag condition might GORD and reduced consciousness, bulging fontanelle or neurological signs suggest?
meningitis or raised intracranial pressure
What red flag condition might GORD and respiratory symptoms suggest?
aspiration and infection
What red flag condition might GORD and blood in stools suggest?
gastroenteritis or cows milk protein allergy
What red flag condition might GORD and signs of infection suggest?
pneumonia, UTI, tonsillitis, otitis or meningitis
What red flag condition might GORD and rash, angioedema and other signs of allergy suggest?
cows milk protein allergy
What is Sandifer’s syndrome?
This is a rare condition causing brief episodes of abnormal movements associated with gastro-oesophageal reflux in infants.
What are the key features of sandifer’s syndrome?
Torticollis and dystonia
What type of muscle is the pyloric sphincter?
Smooth muscle
Where is the pyloric sphincter?
forms the canal between the stomach and the duodenum
What is pyloric stenosis?
Hypertrophy (thickening) and therefore narrowing of the pylorus
What is a major symptom of pyloric stenosis?
Projectile vomiting
How does pyloric stenosis cause projectile vomiting?
After feeding, there is increasingly powerful peristalsis in the stomach as it tries to push food into the duodenum. Eventually it becomes so powerful that it ejects the food into the oesophagus
What might you feel on examination of the abdomen in pyloric stenosis?
A firm, round mass can be felt in the upper abdomen that “feels like a large olive”.
What might you see on a blood gas of a baby with pyloric stenosis?
hypochloric (low chloride) metabolic alkalosis as the baby is vomiting the hydrochloric acid from the stomach.
How do you diagnose pyloric stenosis?
Abdominal ultrasound
What is the treatment for pyloric stenosis?
laparoscopic pyloromyotomy (known as “Ramstedt’s operation“)
What is a laparoscopic pyloromyotomy
An incision is made in the smooth muscle of the pylorus to widen the canal allowing that food to pass from the stomach to the duodenum as normal
What is enteritis?
inflammation of the intestines
What is the main difference between the presentation of gastritis and enteritis?
Gastritis presents with vomiting, enteritis presents with diarrhoea
What is gastroenteritis?
inflammation all the way from the stomach to the intestines and presents with nausea, vomiting and diarrhoea.
Is gastroenteritis infectious?
Yes
What is the main concern in children with gastroenteritis?
Dehydration
What are the key conditions to think about with loose stools?
Infection (gastroenteritis)
Inflammatory bowel disease
Lactose intolerance
Coeliac disease
Cystic fibrosis
Toddler’s diarrhoea
Irritable bowel syndrome
Medications (e.g. antibiotics)
What are the common causes of viral gastroenteritis?
Rotavirus
Norovirus
Adenovirus is a less common cause
What toxin does E.coli 0157 produce?
Shiga toxin
What condition does shiga toxin cause and how?
destroys blood cells and leads to haemolytic uraemic syndrome (HUS)
What can medical professionals prescribe that increases the chance of HUS?
Prescribe antibiotics
What bacteria is a common cause of travellers diarrhoea?
Campylobacter
What is the most common bacterial cause of gastroenteritis worldwide?
Campylobacter
How does campylobacter stain?
Gram negative and is curved or spiralled
What are the possible antibiotic choices for campylobacter?
azithromycin or ciprofloxacin.
How do you treat severe cases of shigella?
Treatment of severe cases is with azithromycin or ciprofloxacin.
What condition can shigella lead to and how?
It produces shiga toxin which can lead to HUS
How does bacillus cereus stain?
gram positive rod
What toxin does bacillus cereus grow on food?
cereulide
How long does it take bacillus cereus to resolve?
24 hours
What bacteria does fried rice left out of the fridge often grow?
Bacillus cereus
How does Yersinia Enterocolitica stain?
gram negative bacillus
Which bacterial cause of gastroenteritis can cause lymphadenopathy?
Yersinia Enterocolitica
Which bacterial cause of gastroenteritis can cause symptoms lasting 3 weeks or more?
Yersinia Enterocolitica
What toxins can staphylococcus aureus produce on food?
Enterotoxins
How long do the symptoms of enterotoxins tend to last?
12 to 24 hours
What is giardia lamblia?
Microscopic parasite
How do you diagnose giardiasis?
Stool microscopy
How do you treat giardiasis?
Metronidazole
What are the possible complications of gastroenteritis?
Lactose intolerance
Irritable bowel syndrome
Reactive arthritis
Guillain–Barré syndrome
What type of condition is coeliac disease?
Autoimmune disease
What cells do the autoantibodies in coeliac disease target?
epithelial cells of the intestine and lead to inflammation
What are the autoantibodies associated with coeliac disease?
Tissue transglutaminase antibodies (anti-TTG)
Endomysial antibodies (EMAs)
Deaminated gliadin peptides antibodies (anti-DGPs)
What part of the small intestine is particularly affected in coeliac disease?
Jejunum
What skin rash do people with coeliac disease sometimes get?
Dermatitis hepetiformis
What condition is often linked to type 1 diabetes?
Coeliac disease
What genes are associated with coeliac disease?
HLA-DQ2 gene (90%)
HLA-DQ8 gene
Why is it important to test total Immunoglobulin A levels when you test for the coeliac antibodies?
Some patients have an IgA deficiency. 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.
What must a person do whilst being investigated for coeliac disease?
Remain on a diet of gluten
What are the initial investigations for coeliac disease?
Check total immunoglobulin A levels to exclude IgA deficiency before checking for coeliac disease specific antibodies:
Raised anti-TTG antibodies (first choice)
Raised anti-endomysial antibodies
What is looked for on biopsy in coeliac disease?
Crypt hypertrophy
Villous atrophy
What conditions is coeliac disease associated with?
Type 1 diabetes
Thyroid disease
Autoimmune hepatitis
Primary biliary cirrhosis
Primary sclerosing cholangitis
Down’s syndrome
What are the complications of untreated coeliac disease?
Vitamin deficiency
Anaemia
Osteoporosis
Ulcerative jejunitis
Enteropathy-associated T-cell lymphoma (EATL) of the intestine
Non-Hodgkin lymphoma (NHL)
Small bowel adenocarcinoma (rare)
What are the features associated with Crohn’s?
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)
Crohn’s is also associated with weight loss, strictures and fistulas.
What are the features associated with Ulcerative Colitis?
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 are the extra-intestinal manifestations of IBD?
Finger clubbing
Erythema nodosum
Pyoderma gangrenosum
Episcleritis and iritis
Inflammatory arthritis
Primary sclerosing cholangitis (ulcerative colitis)
What is first line for inducing remission in Crohn’s?
steroids (e.g. oral prednisolone or IV hydrocortisone).
What are first line treatments for maintaining remission in Crohn’s?
Azathioprine
Mercaptopurine
What are second line treatments for maintaining remission in Crohn’s?
Methotrexate
Infliximab
Adalimumab
What medications are used to induce remission in UC in mild to moderate disease?
First line: aminosalicylate (e.g. mesalazine oral or rectal)
Second line: corticosteroids (e.g. prednisolone)
What medications are used to induce remission in UC in severe disease?
First line: IV corticosteroids (e.g. hydrocortisone)
Second line: IV ciclosporin
What medications are used to maintain remission in UC?
Aminosalicylate (e.g. mesalazine oral or rectal)
Azathioprine
Mercaptopurine
What surgery is available for people with UC?
removing the colon and rectum (panproctocolectomy)
What are the causes of intestinal obstruction?
Meconium ileus
Hirschsprung’s disease
Oesophageal atresia
Duodenal atresia
Intussusception
Imperforate anus
Malrotation of the intestines with a volvulus
Strangulated hernia
What bowel sounds may be heard in intestinal obstruction?
high pitched and “tinkling” early in the obstruction and absent later
What is the initial investigation for intestinal obstruction?
Abdominal X-ray
What will an abdominal x-ray show in intestinal obstruction?
This may show dilated loops of bowel proximal to the obstruction and collapsed loops of bowel distal to the obstruction. There will also be absence of air in the rectum.
What is Hirschprung’s disease?
a congenital condition where nerve cells of the myenteric plexus are absent in the distal bowel and rectum.
What is the myenteric plexus also known as?
Auerbach’s plexus
