Paediatric gastroenterology Flashcards
What is pyloric stenosis ?
-Hypertrophy of the pyloric muscle leading to narrowing and oulet obstruction
Give 4 clinical features of pyloric stenosis
- Projectile vomit
- Hunger after vomiting
- Failure to thrive
- Olive shaped mass in upper abdomen
What would a blood gas show in pyloric stenosis ?
Hypochloric metabolic alkalosis with low plasma sodium and potassium due to vomiting stomach contents
When does pyloric stenosis present ?
- First few weeks of life
What can be seen on abdo exam in pyloric stenosis ?
- Pyloric mass in RUQ (olive like )
- Gastric peristalsis seen as a wave moving from left to right across the abdomen
How is pyloric stenosis diagnosed ?
- Test feed
- USS
How is pyloric stenosis managed ?
- Ramstedt’s pyloromyotomy
- Correct fluid and electrolyte disturbance with IV fluids
Define biliary atresia
- Section of the bile duct is either narrowed or absent
- This leads to cholestasis, where bile cannot be transported from the liver to the bowel
How does biliary atresia present
- Persistent jaundice shortly after birth
- Dark urine, pale stools
- Hepatosplenomegly
Define prolonged jaundice in term and premature babies
- Term : 14 days
- Premature : 21 days
What investigations are used in biliary atresia ?
- Raised levels of conjugated bilirubin
- There will be a high proportion of conjugated bilirubin (the liver can process it but not excrete it)
How is biliary atresia managed?
- > Kasai portoenterostomy : attaching a section of the small intestine to the opening of the liver where the bile duct normally attaches.
- > Often require a liver transplant in later life
Define Hirschsprung disease
-Congenital condition where the nerve cells in the myenteric plexus are absent (aganglionic) in the rectum and variable distance of the colon
Give 4 presenting signs of Hirschsprung
- Failure to pass meconium in the first 24 hrs of life
- Abdominal distention
- Later : bile-stained vomit
- If presentation is later in life : profound chronic constipation, abdo distention and growth failure
How is Hirschsprung diagnosed ?
-Suction rectal biopsy
How is Hirschsprung managed ?
- Initially : rectal washouts/irrigation to prevent enterocolitis
- Surgically : initial colostomy with removal of the aganglionic section, followed by anastomosing normally innervated bowel the the anus -> swenson
What is a severe complication of Hirschsprung disease ?
-Hirschsprung-Associated Enterocolitis (HAEC)
What can cause HAEC and how does it present ?
- C.diff
- Fever, abdo distention, diarrhoea (often bloody) and features of sepsis
How is HAEC managed ?
- IV antibiotics
- Fluid resus
- Decompression of obstructed bowel
what conditions is hirschsprung’s associated with ?
- Down’s
- Waardenburg
What is intussusception and when does it occur?
- Invagination of proximal bowel into a distal segment
- Usually occurs between 6mnths and 2 yrs of age
How does intussusception present
- Concurrent viral illness !
- Severe colciky pain and pallor causing a child to draw their legs up
- Redcurrant jelly stool
- Palpable sausage shaped mass in the abdomen
- Intestinal obstruction : vomiting, constipation, abdo distention.
What is associated with intussusception
- Meckel diverticulum
- Henoch-Schonlein purpura
- Cystic fibrosis
- Intestinal polyps
What is Meckels diverticulum and how does it present ?
- Ileal remnant of the vitello-intestinal duct
- Presents with severe rectal bleeding : most common cause of painless massive GI bleeding requiring transfusion between the ages of 1 and 2.
- Diverticulitis micking appendicitis.
- Often haemadynamically unstable due to the bleeding.
- Treated with surgical resection
How is intussusception diagnosed ?
- USS : target sign
- Contrast enema
How is intussusception managed ?
- Rectal air insufflation : therapeutic enema
- Surgery if reduction of air is ineffective
How is intussusception managed if there are signs of peritonitis ?
- Surgery
Give 4 complications of intussusception
- Obstruction
- Gangernous bowel
- Perforation
- Death
What are the symptoms of an appendicitis ?
- Umbilical pain that spreads to the RIF
- Anorexia
- N&V
What are the signs of an appendicitis ?
- > Tenderness and guarding over McBurney’s point
- > Rovsing’s sign : palpation in LIF causes pain in the RIF
- > Fever
- > Abdo pain aggravated my movement
Give 2 signs of peritonitis
- Rebound tenderness : increased pain following quick release of pressure of RIF
- Percussion tenderness
Give 3 complications of an appendicitis
- Rupture -> peritonitis
- Abscess
- Appendix mass
What is malrotation ?
-Malrotation of the small bowel during foetal life
How does malrotation present ?
- Bilious vomiting in the first few days of life
- can lead to volvus formation leading to an obstruction and ischaemic bowel
- Abdo pain and tenderness from peritonitis or ischaemic bowel
- Associated with exomphalos & hernia
How is malrotation diagnosed ?
- Upper GI contrast study
- Abdo USS : whirlpool sign
How is malrotation managed ?
-Surgery to untwist the bowel : Ladd’s
how will an intestinal obstruction present
- Persistent vomiting. This may be bilious, containing bright green bile.
- Abdo pain and distention
- Failure to pass stools or wind
- Abnormal bowel sounds. These can be high pitched and “tinkling” early in the obstruction and absent later
What are the differentials of intestinal obstruction in a child
- Meconium ileus
- Malrotation with volvus formation
- Hirchsprung’s
- Intussusception
- Oesophageal atresia
- Duodenal atresia
- Imperforate anus
- Strangulated hernia
What is mesenteric adenitis and how does it present
- Inflammation of the lymph nodes in the abdomen
- Central abdominal pain and concurrent URTI
How are simple cases of GORD in children managed ?
- Small, frequent meals
- Burping regularly to help milk settle
- Not over-feeding
- Keep the baby upright after feeding (i.e. not lying flat)
How can more problematic cases of GORD in children be managed ?
- Gaviscon mixed with feeds
- Thickened milk or formula
- PPI : if -> faltering growth, distressed behaviour
What is Sandifer’s syndrome ?
- Episodes of abnormal movement associated with GORD in infants
What are the key features of sandifer’s syndrome
- Torticollis: forceful contraction of the neck muscles causing twisting of the neck
- Dystonia: abnormal muscle contractions causing twisting movements, arching of the back or unusual postures
Exam question : child <5 presents with watery loose stools containing bits of vegetables up to 10 times a day. What is the diagnosis ?
Toddler’s diarrhoea
what are the genetic associations with coeliac disease ?
HLA-DQ2 gene (90%)
HLA-DQ8 gene
what auto-antibodies are seen in coeliac disease and what damage do they cause
- Anti-tissue transglutaminase (anti-TTG)
- Anti-endomysial (anti-EMA)
- Target the epithelial cells leading to inflammation -> causing atrophy of the intestinal villi and crypt hypertrophy. Particularly in the jejnum
How can coeliac disease present in children?
- Failure to thrive
- Diarrhoea
- Fatigue
- Weight loss
- Mouth ulcers
- Anaemia
- Dermatitis herpetiformis on the abdomen
what neurological symptoms can rarely be seen in coeliac disease
Peripheral neuropathy
Cerebellar ataxia
Epilepsy
what needs to be tested before looking at the antibodies involved in coeliac screening ?
- Total IgA levels
- If total IgA is low the coeliac test will be negative even when they have the condition as anti-TTG and anti-EMA are IgA antibodies
what 3 malignancies are recognised complications of untreated coeliac disease ?
- Enteropathy-associated T-cell lymphoma (EATL) of the intestine
- Non-Hodgkin lymphoma (NHL)
- Small bowel adenocarcinoma (rare)
Define crohns disease
-Transmural granulomatous chronic inflammation of the GI tract
How does crohns disease present ?
- Abdo pain, diarrhoea, weight loss
- Growth failure due to malabsorption
- Delayed puberty
What are the extraintestinal symptoms of crohns?
- Oral lesions or perianal skin tags
- Uveitis
- Arthralgia
- Erythema nodosum
What bloods are seen in crohns ?
- Raised faecal calprotectin
- Raised plts, ESR and CRP
- IDA due to malabsorption
- low serum albumin
What is seen on endoscopy + biopsy in crohns
- Skip lesions
- Non-caseating granulomas
- Transmural damage, terminal ileum most severe
How is remission induced in crohns ?
- Nutritional therapy for 6-8 wks
- Systemic steroids if necessary (oral pred, IV hydrocortisone)
How is remission maintained/relapse treated in crohns?
- Immunosuppressant medication : azathioprine, mercaptpurine, methotrexate
- Infliximab, adalimumab if necessary
Give 3 complications of crohns
- Bowel strictures leading to obstruction
- Fistulae
- Abscess formation
Define ulcerative colitis
-Recurrent, inflammatory and ulcerating disease involving the mucosa of the colon
How does UC present ?
- Rectal bleeding, diarrhoea and colicky abdo pain
- Weight loss
- Growth failure
Give 3 extraintestinal signs of UC
- Arthritis
- Erythema nodosum
- Primary sclerosing cholangitis
Give 3 signs of UC on endoscopy + biopsy
- Continuous inflammation
- Begins in the rectum and travels proximally
- Possible crypt abscesses
How is remission induced in UC ?
- Mild : aminosalicylates (e.g. mesalazine) or corticosteroids
- More severe : IV corticosteroids or IV ciclosporin
How is remission maintained in UC
- Aminosalicylate
- Azathioprine
- Mercaptopurine
What is a complication of UC ?
-Increased risk of adenocarcinoma of the colon in adulthood
Give 3 common causes of viral gastroenteritis
- Rotavirus
- Norovirus
- Adenovirus -> less common, more subacute diarrhoea
How would E.coli present if causing gastroenteritis
- Abdo cramps, bloody diarrhoea, vomiting.
- The shiga toxin leads to HUS
- Abx should be avoided due to increased risk of HUS
What is the most common bacterial causes of gastroenteritis worldwide ?
- Campylobacter jejuni -> gram neg
- Abdo cramps, bloody diarrhoea, vomiting, fever
- Raw poultry, untreated water, unpasteurised milk
- Abx : azithromycin, ciprofloxacin
How would shigella gastroenteritis present ?
- Faeces contaminated food and water
- Bloody diarrhoea, abdo cramps, fever
- Shiga toxin -> HUS
- Severe : azithromycin or ciprofloxacin
Explain salmonella causes of gastroenteritis
- Raw eggs, poultry
- Watery diarrhoea with possible mucus or blood
- Abx only in severe cases
How does bacillus cereus as a cause of gastroenteritis present ?
- Fried rice eaten at room temp
- Cereulide toxin produces abdo cramping and vomiting withing 5 hrs
- Diarrhoea within 8 hrs
- Resolves within 24
- Gram positive rod
Give a parasitic cause of gastroenteritis
- Giardia lamblia
- Chronic diarrhoea
- Tx : metronidazole
- Tx with metronidazole
What are the principles of gastroenteritis management
- Barrier nursing
- Stool microscopy, culture and sensitivities
- Hydration -> attempt fluid challenge. Dioralyte can be used to rehydrate or IV fluid is needed
How can intestinal obstruction present and how is it diagnosed ?
- Persistent, possibly bilious vomiting
- Abdo pain and distention
- Failure to pass stool or wind
- Abnormal bowel sounds : high pitched ‘tinkling’, absent later
- XRAY : dilated bowel proximal and collapsed loops distal + absence of air in rectum
Define encopresis
- Faecal incontinence -> pathological at 4 yrs
- Chronic constipation causes the rectum to stretch and lose sensation.
- Only loose stool can bypass blockage and leak out
How is constipation managed if faecal impaction is present ?
- Movicol peadiatric plan
- Add stimulant after 2 wks if no change (e.g. bisacodyl, senna)
- Add osmotic laxative (lactulose)
How is general constipation managed
- Movicol paediatric plan
- Add stimulant
- Add osmotic laxative
- Continue for several weeks after refulat bowel habit.
- Bacteria most commonly affecting children
- Causes watery or blood diarrhoea, abdo pain, fever and lymphadenopathy
- Can mimic appendicitis by causing mesenteric lymphadenitis in older children
- Caused by raw or undercooked pork
Yersinia enterocolitica
What is an abdominal migraine
- Episodes of central abod pain, lasting >1 hr
- Possible associated : Nausea and vomiting, Anorexia, Pallor, Headache, Photophobia, Aura
How are acute attacks of abdominal migraines managed ?
- Low stimulus environment (quiet, dark room)
- Paracetamol
- Ibuprofen
- Sumatriptan
What is the main preventer used in abdominal migraines ?
Pizotifen -> serotonin agonist
