Paediatric Gastroenterology Flashcards
1
Q
What is the most common congenital gastrointestinal abnormality?
A
Meckel’s diverticulum
2
Q
What is a true diverticulum?
A
Contains all 3 layers of the bowel wall
3
Q
What is Meckel’s diverticulum due to?
A
A remnant of the vitello-intestinal duct of the embryo, ectopic gastric mucosa
4
Q
When would the attachment between the vitello-intestinal duct and the yolk sac normally disappear?
A
6 weeks gestation
5
Q
Where is Meckel’s diverticulum located?
A
On the anti-mesenteric border of the ileum and it is a true diverticulum
6
Q
In what age groups does Meckel’s diverticulum usually present?
A
Infants and toddlers - NOT neonatal
7
Q
What is used to memorise information about Meckel’s diverticulum?
A
Rule of 2s
8
Q
What are the 4 parts of the rule of 2s in Meckel’s diverticulum?
A
1) Male:female ratio of 2:1
2) Usually approx 2 inches in length
3) 2 feet proximal to caecum
4) Occurs in approx 2% of population
9
Q
Is Meckel’s diverticulum more common in males or females?
A
Males (2:1)
10
Q
How can Meckel’s diverticulum present?
A
1) Symptomless
2) Patent vitello-intestinal duct of the embryo - may be discharging intestinal contents
3) Painless rectal bleeding
4) Abdominal pain (diverticulum inflammation)
5) Intussusception - may act as the apex for ileoileal type
6) Obstruction (if it becomes trapped in a hernia) - bilious vomiting
7) Perforation by a foreign body
11
Q
Why can painless rectal bleeding occur in Meckel’s diverticulum?
A
Due to ulceration of adjacent tissue as the diverticulum may contain ectopic gastric tissue that produces acid
12
Q
What is a hernia called that has Meckel’s diverticulum trapped inside of it?
A
Littre’s hernia
13
Q
What investigations are done for Meckel’s diverticulum?
A
1) CT scan
2) 99mTC scan - taken up by gastric mucosa if present ectopically
3) (Small bowel enema)
14
Q
How is Meckel’s diverticulum managed?
A
1) Treat clinical presentation e.g. obstruction - decompression with NG tube
2) Resection of diverticulum (wedge excision or small bowel resection and anastomosis)
15
Q
What are 3 potential complications of Meckel’s diverticulum?
A
1) Intussusception - may act as the apex for ileoileal type
2) Obstruction - if it becomes trapped in a hernia (Littre’s hernia)
3) Perforation by a foreign body
16
Q
What signs would acute (obstructed) Meckel’s diverticulum show in an abdominal exam?
A
1) Distension
2) Tender to palpation worst in the midline and RIF
17
Q
What would an inflamed or obstructed Meckel’s diverticulum show on abdominal ultrasound?
A
Small fluid filled pouch off the distal small intestine
18
Q
When should intussusception be considered?
A
In young infants or toddlers with screaming attacks
19
Q
What is intussusception?
A
When one portion of bowel prolapses into the lumen of the adjacent bowel
20
Q
What does intussusception look like on abdo US?
A
Telescoping appearance
21
Q
How does intussusception present?
A
1) Redcurrant jelly stools
2) Sausage shaped mass in RUQ
3) History of being unwell 1-3 days prior to presentation
4) Paroxysms of colicky abdominal pain and crying
5) Bile-stained vomiting
22
Q
In which age group is intussusception most common?
A
3-12 (5-7) months
23
Q
How do you manage intussusception if the child is relatively well?
A
Attempt pneumatic reduction under fluoroscopic guidance
24
Q
How do you manage intussusception if the child is unwell or perforation is suspected?
A
Laparotomy
25
How can viral gastroenteritis present in a toddler?
1) Vomiting and/or diarrhoea
2) Fever
3) Watery stools (but no feature of obstruction)
4) Other members of family unwell
26
What is an important cause of viral gastroenteritis to consider?
COVID-19 (GI symptoms e.g. D&V are common in children and may be the only feature with an absence of resp symptoms)
27
When does meconium ileus present?
Neonatal period
28
What condition is present in 80% of neonates with meconium ileus?
Cystic fibrosis (may have additional features such as failure to thrive)
29
What would an AXR show in meconium ileus?
1) Distended bowel
2) 'Ground-glass' appearance of viscous meconium
30
What is first instance treatment of meconium ileus?
Attempting to clear the blockage with gastrograffin - as this is a hyperosmolar agent and will draw fluid into the lumen
31
What is an important differential to Meckel's diverticulum in the older child?
Appendicitis - may have similar features if the pain is due to diverticulum inflammation
32
What would an AXR show in inflamed or obstructed Meckel's diverticulum?
Non-specific features of obstruction
33
When does Hirschsprung disease present?
Neonatal period (at birth) - first few days of life
34
How does Hirschsprung disease present?
1) Failure to pass meconium in the first 48h of life
2) Features of obstruction - bilious/feculent vomiting, abdominal distension/tenderness
3) Forceful evacuation of meconium after DRE
4) Feeding intolerance
35
What is Hirschsprung disease?
1) A congenital condition of aganglionic distal bowel (commonly rectum), causing distension proximal to this segment
2) As the baby develops in utero, the distal colon is not innervated correctly. The resulting aganglionic colon is shrunken and not able to distend properly. This causes a back pressure of stool trapped in the more proximal colon.
36
What is an emergency complication of Hirschsprung disease and how is it treated?
Hirschsprung-related enterocolitis - emergency requiring rectal decompression
37
Which gene has been implicated with Hirschsprung disease?
RET proto-oncogene
38
How is Hirschsprung disease diagnosed and what is seen?
Rectal suction biopsy (at least 1.5cm above the pectinate line) - will show absence of ganglionic cells, unlike in an acquired megacolon + presence of thickened, non-myelinated nerves
39
What is conservative treatment of Hirschsprung disease?
Regular enemas
40
What is neonatal surgical treatment for Hirschsprung disease?
1) Initial colostomy in the acute emergency obstruction
2) Definitive treatment - later elective resection of the affected segment with anastomosis between the normal colon and anal canal - removal of the section of aganglionic colon and the healthy bowel is pulled through
41
What is the vomiting typically like in intussusception?
Non-bilious vomiting
42
What is necrotising enterocolitis (NEC)?
A very serious condition in which the bowel of premature infants becomes ischaemic and infected - cause is unclear, fatal in 1/5 of cases
43
What are the risk factors for necrotising enterocolitis?
1) Prematurity
2) Low birth weight
3) Non-breast-milk feeds e.g. cow's milk formula
4) Sepsis
5) Acute hypoxia
6) Poor intestinal perfusion
44
In which age group does necrotising enterocolitis usually present?
Premature neonates in the first 3 weeks of life
45
How does necrotising enterocolitis present?
1) Vomiting - may be bile-streaked
2) Bloody stools - streaked with fresh red blood
3) Abdominal distension
4) Absent bowel sounds
5) Signs of systemic compromise
46
What might you see on blood gas in necrotising enterocolitis?
Acidosis
47
How is necrotising enterocolitis diagnosed?
Abdominal X ray
48
What would you see on abdominal x ray in necrotising enterocolitis?
1) Dilated bowel loops
2) Pneumatosis intestinalis (gas within the bowel) - intramural air (thin black lines within the white bowel walls)
3) Portal venous gas
4) Pneumoperitoneum
49
Which classification is used to stage necrotising enterocolitis?
Bell's classification - uses a mix of clinical signs and radiological findings
50
How do you manage necrotising enterocolitis?
1) NBM, NG tube + neonatal unit admission
2) Broad-spectrum antibiotics
3) Total parenteral nutrition to rest the bowel
4) Supportive treatment - IV fluids + ventilation
5) Surgery - to resect necrotic sections of bowel may be necessary and is essential in cases of bowel perforation - contact paediatric surgeons early and may need to transfer patient to neonatal surgical unit
51
When is surgery for necrotising enterocolitis essential?
In cases of bowel perforation (1 in 3 babies with NEC)
52
What are potential significant long term implications for infants that survive necrotising enterocolitis?
Having a stoma or short gut syndrome
53
What are two recommendations to try and prevent necrotising enterocolitis?
1) Breastfeeding - strongly encourage mothers of premature babies to breastfeed, reduces risk of NEC
2) Delayed cord clamping at delivery - reduces the risk of NEC in premature babies
54
What is the treatment for retinopathy of prematurity?
Retinal laser therapy
55
What are differentials for vomiting in younger children?
1) Posseting - small volumes of milky fluid after feeds
2) GORD - larger volume regurgitation
3) Infection - forceful vomits non-specific sign of any infection in infants - need thorough examination incl. ENT
4) Whooping cough - vomiting after prolonged periods of coughing
5) Pyloric stenosis - projectile vomiting at 6-8 weeks of age while feeding
6) GI obstruction - bilious vomiting e.g. malrotation
7) Appendicitis
8) Testicular torsion
9) Brain tumour
56
What are additional differentials for vomiting in older children?
1) DKA
2) Cyclical vomiting
3) Migraine
4) Alcohol & drug use esp. cannabis
5) Bulimia
6) Pregnancy
7) Raised ICP - early morning headaches and vomiting
57
What is initial management of GORD in young children?
Conservative - positioning and burping advice
58
How would a ruptured appendix present?
1) Fever, abdo pain, D&V
2) Not eating
3) Pale
4) Generalised tenderness with guarding and tenderness to percussion
5) Tachycardia
6) Hypotension
59
How is a ruptured appendix managed?
Immediate septic management (IV fluids + antibiotics) and then surgery
60
How does appendicitis typically present in children?
1) Central abdo pain (severe peri-umbilical pain) which later radiates/localises to RIF
2) Nausea, vomiting ± anorexia
3) Low-grade pyrexia
4) Localised tenderness, guarding and rebound tenderness can be elicited in the RIF
61
How does testicular torsion present?
1) Abdominal pain
2) Swollen, tender testis retracted upwards
62
How is constipation defined in children?
Defaecates < 3 times per week OR significant difficulty passing stool
63
How does chronic constipation present in children?
1) Hard pellet like stool that is difficult to pass
2) Overflow diarrhoea from fluid moving past the hard stool in the rectum
64
What is the most common cause of chronic constipation in children?
Diet
65
What are reasons why children can become constipated?
1) Low fibre diet
2) Dislike of using toilet
3) Pain on passing stool e.g. secondary to anal fissure or very hard stool
4) Not recognising sensation of needing to pass stool
66
How is chronic constipation diagnosed in children?
1) History
2) Examination - palpation of impacted faeces - hard depressible masses on abdo exam
67
How is chronic constipation in children managed?
1) Initial treatment = movicol disimpaction regimen (movicol = macrogol laxative)
2) Followed by maintenance movicol
3) High fibre diet + advice about encouraging good toileting habits
68
What is an example of a gastro condition that can cause chronic constipation?
Hirschsprung's disease
69
How can children present later in childhood with Hirschsprung's disease?
1) Chronic history of constipation with poor response to movicol disimpaction regimens
2) Poor weight gain
70
How does mesenteric adenitis present?
1) Diffuse non-specific abdo pain/generalised abdo tenderness (guarding is rare and would not produce septic picture like appendicitis)
2) Recent URTI e.g. pharyngitis
3) Low-grade fever
4) Well child with normal appetite
71
What is the first line investigation for mesenteric adenitis?
Abdominal ultrasound
72
What will you see on abdominal ultrasound in mesenteric adenitis?
Enlarged mesenteric lymph nodes ± mesenteric thickening with a normal appendix (appendix may not always be visualised on US so need to take clinical presentation into account when ruling out appendicitis)
73
How is mesenteric adenitis monitored?
Conservative - often children may be monitored overnight to look for worsening of their clinical status or safety-netted about returning if any concerns arise (mesenteric adenitis will improve spontaneously, appendicitis will not)
74
How do you investigate intussusception?
1) Abdo US
2) Barium enema
75
What investigation is done when a child presents with a suspected ulcer + preceding reflux symptoms?
Helicobacter pylori breath test
76
What are the characteristics of gastro-oesophageal reflux (GOR) in children?
1) GOR = the passage/reflux of gastric contents incl. acid into the oesophagus
2) Considered physiological in infants when symptoms are absent or not troublesome
3) Affects up to 40% of children during first 6 months of life
4) It is common as the gastro-oesophageal sphincter is still developing
77
How do babies common present with GOR?
1) Milky vomits after feeds (non-bloody and non-bilious)
2) Crying/irritability
3) Arching of the back (can be mistaken for seizures)
4) Drawing up of the knees into the chest
- Feeding habits may or may not be affected
78
How do you manage GOR in infants?
1) Conservative - keep baby upright post-feeds and burp after feeds, keep cot on a slight incline, reassure parents that most cases will resolve as the baby grows and cardiac sphincter matures
2) Medical - gaviscon (infant formulation), omeprazole
3) Surgical - fundoplication
79
How does duodenal atresia present?
Bilious vomiting from birth, presents during first week of life
80
When does pyloric stenosis typically present?
First 6 weeks of life (6-8 weeks)
81
Which sex is more affected by pyloric stenosis?
Boys
82
How does pyloric stenosis present?
1) Forcefully projectile and non-bilious (yellow) vomiting straight after feeding - increasing in frequency with every episode as obstruction becomes more severe
2) Weight loss
3) Smooth olive shaped mass (hypertrophic pyloric sphincter) in RUQ/epigastric (esp. after feeding)
4) Persistent hunger
5) Dehydration
6) Lethargy
83
When does cow's milk protein allergy typically present?
In the first year of life
84
How does cow's milk protein allergy present?
Extensive diarrhoea ± blood in stool
85
When does intestinal volvulus present?
First month of life
86
How does volvulus present?
1) Sudden onset recurrent bilious vomiting - a child with green or yellow vomiting should be presumed to have volvulus until proven otherwise
2) Other signs of obstruction
3) Blood in nappies
87
What is the most common cause of infantile gastroenteritis?
Rotavirus
88
What is a common cause of respiratory infections that can also cause gastroenteritis esp. in children?
Adenoviruses
89
What can be used as an anti-emetic in paediatric gastroenteritis as an adjunct to fluid replacement?
Ondansetron
90
What is malrotation?
Rare but extremely important diagnosis to make
1) In malrotation, early in development the midgut rotates and fixates in an abnormal position
2) This abnormal position makes the bowel more prone to volvulus and for the duodenum to be compressed by peritoneal bands (Ladd bands)
3) The bowel loops partially rotate into their anatomical position during development
91
How does malrotation present?
Bilious vomiting within the first day of life
92
How is malrotation diagnosed?
1) Upper GI contrast study (barium enema) - will identify the point of the obstruction (as no contrast can pass distally from this location)
2) The proximal bowel may be shaped like a corkscrew
93
How is malrotation managed?
Urgent surgery to relieve the obstruction
94
What is volvulus?
Complete twisting of bowel loop around its mesenteric attachment site (associated with malrotation)
95
How does jejunoileal/jejunal atresia present?
On first or second day of life:
1) Increased abdominal distention
2) Failure to pass stools
3) Vomiting
4) Feeding problems
5) History of polyhydramnios
96
Who is commonly affected by acute appendicitis?
Young children > 10 years of age
97
What would AXR show in malrotation + volvulus?
Dilatation of the stomach + proximal loops of bowel
98
What would barium enema show in malrotation + volvulus?
Partial obstruction of the duodenum + malposition of caecum
99
What is pyloric stenosis?
Hypertrophy of the pyloric sphincter
100
What are complications of pyloric stenosis?
1) Severe vomiting may lead to an acid-base abnormality of hypochloraemic hypokalaemic metabolic alkalosis
2) Dehydration
101
What might you see on blood gas in pyloric stenosis due to severe vomiting?
Metabolic alkalosis - low chloride and low potassium
102
How is pyloric stenosis diagnsoed?
Abdominal ultrasound - to visualise the hypertrophic sphincter
103
How do you manage pyloric stenosis?
1) Surgical - pyloromyotomy to cute the pyloric sphincter to widen the outlet
2) Until the surgery - NBM + IV fluids
3) If severely dehydrated - acute fluid resuscitation
104
What would be seen on AXR in Hirschsprung's disease?
Dilated proximal colon with air fluid levels present
105
What would be seen on contrast enema in Hirschsprung's disease?
Valuable screening investigation - dilated descending colon, followed distally by a contracted recto-sigmoid (aganglionic) segment
106
What is the key treatment for NEC?
Broad spectrum abx + parenteral feeding
