Paediatric gastroenterology Flashcards
Coeliacs in children : Definition
Sensitivity to gluten - repeated exposure leads to villous atrophy which in turn causes malabsorption
Coeliacs in children : Age of presentation
Before 3 years old - following introduction of cereals into diet
Coeliacs in children : Clinical features
- Failure to thrive - low BMI, height
- Abdominal pain and distention
- Diarrhea
Coeliacs in children : Diagnosis
- Biopsy of the jejunum : subtotal villous atrophy
- Bloods : Anti-endomysial and anti-gliadin antibodies
Constipation in children : average BO for children
< 6 months : average 3 times a day
+3 years : Once a day
Constipation in children : Life style causes
- Habitually not opening the bowels
- Low fibre diet
- Poor fluid intake and dehydration
- Sedentary lifestyle
- Psychosocial problems such as a difficult home or school environment
Constipation in children : Secondary causes
Diet : Low fibre diet and dehydration, Cow’s milk intolerance
Anal stenosis : Anal fissure, IBD
Hirschsprung’s disease
Hypothyroidism
Constipation in children : Most common cause
Idiopathic - majority of children, cause is unknown
Constipation : Diagnosis in children
2 or more symptoms of the following:
-
Stool pattern
1. Less than 3 stools a week
- Hard large stool which is difficult to pass
- ‘Rabbit dropping stool’
- Overflow soiling - Faecal impaction causing overflow soiling, with incontinence of particularly loose smelly stools
-
Symptoms associated with defecation
1. Pain
1. Straining and painful passages of stools
1. Abdominal pain and poor appetite which improved with passage of stool
1. Rectal bleeding associated with hard stool -
Signs
1. Holding an abnormal posture, referred to as retentive posturing
1. Hard stools may be palpable in abdomen
1. Loss of the sensation of the need to open the bowels
Constipation : Diagnosis of Idiopathic Constipation
- Step 1 : Diagnosis of Constipation
- Step 2 : Rule of secondary causes of constipation by considering the following symptoms
- > 48 hours for meconium passage
- ‘Ribbon’ stool : indicates anal stenosis - may be secondary to anal fissure/ IBD
- Failure to thrive - low weight, height
- Neurological weakness/development delay
- Step 3 : If ruled out - can diagnose idiopathic constipation
Constipation : Faecal incontinence
Considered pathological > 4 years
1. Sign of chronic constipation
2. Rectum becomes stretched chronically and looses sensation
3. Hard stool remains and only loose stool are able to bypass the blockage - leaking out without sensation
4. ‘Overflow soiling’
Constipation : Faecal impaction
- Habit of not opening bowels and ignoring sensation of full rectum
- Lose sensation to open bowels - reduced frequency of bowel opening
- Retention of faeces .
- Faecal impaction : large, hard stool block the rectum
Symptoms are : severe constipation, overflow soiling, faecal mass in abdomen
Constipation : Management of faecal impaction
First line : Polyethylene glycol + Movicol } both osmotic laxatives
If no disimpaction in 2 weeks
Second line : Add stimulant laxative (Senna)
Constipation : Maintainance therapy
- First line : Movicol
If no response - Second line : Add stimulant laxative (Senna)
Appendicitis : Incidence in children
- Occurs in children > 4 years
- If < 4 years : Presents with perforation
Hirschsprung’s disease : Definition
congenital condition characterised by partial or complete colonic functional obstruction associated with the absence of ganglion cells
Hirschsprung’s disease : Pathophsyiology
- Development failure results in lack of parasympathetic plexus innervation of a segment of the bowel
- Aganglionic segment of the bowel results in uncoordinated peristalsis of the bowel
- Functional obstruction
Hirschsprung’s disease : Risk factors
- 3x more common in males
- Down’s syndrome
Hirschsprung’s disease : Incidence
new-born period to 1 year of age
Hirschsprung’s disease : Clinical features
Neonatal period
-Delay of > 48 hr or failure to mass meconium
Older children
-Constipation and abdominal distention
-Vomitting
-Failure to thrive
Hirschsprung’s disease : Investigations
- Rectal biopsy : Gold standard for diagnosis
- Abdominal X-ray
Hirschsprung’s disease : Management
- Initial management
- Rectal washout/ Bowel irrigation : poor peristalsis means stool/flatus is not completely cleared - Definitive management
- Surgery to affected segment of the colon
Cow’s milk protein allergy/intolerance : Definition
- Immune-mediated allergic response to proteins in the milk
- It is one of the most common childhood food allergies
- Allergy : Immediate IgE mediated
- Intolerance : Delayed, non IgE mediated
Cow’s milk protein allergy/intolerance : Incidence
< 3 month old infants - formula fed infants,
Very rare in breast fed infants
Cow’s milk protein allergy/intolerance : Risk factors
Formula fed infants
Cow’s milk protein allergy/intolerance : Clinical features
- After feeds ;
* Regurgitation and Vomiting
* Diarrhoea
2 . Atopy symptoms `; Urticaria, Ectopic eczema, wheeze
3 . Colic symptoms : Irritability, crying
Cow’s milk protein allergy/intolerance : Diagnosis
- Clinical diagnosis : Improvement with cow’s milk protein elimination
Cow’s milk protein allergy/intolerance : Investigations
- Skin prick/patch testing
- Total IgE and specific IgE (RAST) for cow’s milk protein
Cow’s milk protein allergy/intolerance : Management
Formula fed
1. First line
* Mild-moderate sx : Extensive hydrolysed formula milk
- Second line
* Severe sx or no response to eHF : Amino acid-based formula
Breast fed
1. Eliminate cow’s milk from maternal diet
Cow’s milk protein allergy/intolerance : Prognosis
Resolves on its own in most children
* IgE mediated - 55% will be milk tolerant by 5 years old
* Non-IgE - Most will be milk tolerant by age 3
Paediatric GORD : definition
Pathological regurgitation of oesophageal contents - regurgitation is not physiological and is associated with other symptoms
Paediatric GORD : Incidence
< 8 week infants
Paediatric GORD : Clinical features
- Vomiting / Regurgitation
-Milky vomits after feeds
-May occur after being laid flat - Failure to thrive
- Distressed behaviour / Feeding aversion - excessing crying especially when feeding, refusing to feed, gagging
Paediatric GORD : Diagnosis
Clinical diagnosis
Paediatric GORD : Management
- Feeding position : -30 degrees, head up
- Avoid overfeeding : Smaller, more frequent feeds
- Trail - not at the same time
* Aligante : Gaviscon
* Thickening agent
Paediatric GORD : Management with PPI
Trail PPI only if one of the following symptoms apply with regurgitation;
1. Feeding aversion : refusing feeds, gagging, choking
2. Distressed behaviour
3. Failure to thrive
Paediatric GORD : Complication
- Failure to thrive
- Aspiration : Pneumonia
Intussusception : Definition
- Inversion of one portion of the intestine with another
- Commonly in ileo-caecal region
- Most common cause of bowel obstruction in children
Intussusception : Incidence
- 6 months - 1 1/2 year olds
- Mainly Boys x2 as often
Intussusception : Clinical features
- Abdominal pain ;
* Intermittent, severe, crampy abdominal pain
* During episode - Infant will draw knees up and turn pale
2 . Insonsolable crying (due to pain)
3 . Vomitting
4 . Bloodstained stool - ‘Red-currant jelly’
Intussusception : Clinical sign
- sausage-shaped mass in the right upper quadrant
Intussusception : Investigation
US Abdomen : Target-like mass
Intussusception : Management
First line : Reduction by air insufflation } creates pressure within the intestines and seperate them
Pyloric stenosis : Definition
Condition where the muscle passage (pylorus) between the stomach and small bowel (duodenum) becomes hypertrophied and narrows.
Pyloric stenosis : Clinical features
- Projectile vomiting - 30 minutes after feed
High frequency of vomiting leads to; - Hypochloraemia, Hypokalaemia Alkalaosis
- Dehydration —> Constipation
Pyloric stenosis : Clinical signs
Palpation : ‘Olive’ Mass in the upper abdomen
Pyloric stenosis : Incidence
< 4 week old infants
Pyloric stenosis : Investigation for diagnosis
Abdominal US
Pyloric stenosis : Management
Ramstedt Pyloromyotomy
Biliary atresia : definition
Congential abnormality of obstruction of the bile ducts leading from the liver secondary to narrowing.
Biliary atresia : Pathophysiology
- Congential abnormality characterised by the narrowing of the bile ducts this leads to
- Obstruction of the biliary ducts which transport bile from the Liver to the Gall bladder and small intestine.
- Bile and its components (conjugated bilirubin) back up in tot liver and are released in the blood
Biliary atresia : Clinical presentation
- Jaundice peresistent > 14 days after birth
- High levels of conjugated bilirubin } indicates obstructive disease
Biliary atresia : Management
Surgery - “Kasai portoenterostomy”
-Attach small section of small intestine to opening of the liver
Meckel’s diverticulum - definition
A congenital out-pouching - diverticulum present in the small intestine at birth
Meckel’s diverticulum - Pathophysiology of development
- < week 8 of development : The omphalmomesenteric duct delivers nutrients from the yolk sac to the midgut/small intestine for developmen
- Normally : narrows and disappears before week 8
- Pathology : Proximal part of the vitelline duct fails to regress and remains a part of the small intestine
Meckel’s diverticulum - Anatomy
Meckel’s diverticulum contains;
1. Pluripotent embryonic cells from other tissue times : ectopic illeal, gastric or pancreatic mucosa
- Has its own blood supply : Omphalomesenteric artery } prone to obstruction
Meckel’s diverticulum : Rule of 2s
- 2% (of the population)
- 2 feet (proximal to the ileocecal valve
- 2 inches (in length)
- 2 types of common ectopic tissue (gastric and pancreatic)
- 2 years is the most common age at clinical presentation
- 2:1 male:female ratio
Meckel’s diverticulum : Clinical features
Usually asymptomatic
1.Abdominal pain - similar to appendicitis
2. Rectal bleeding : most common cause of severe painless GI bleeding in children
3. Vomitting / Constipation
Meckel’s diverticulum : Complications
- Diverticulitis
- Ulcers : from HCL secretion of gastric mucosa
- Intestinal obstruction : intussusception, volvulus
- Perforation
Meckel’s diverticulum : Investigation
- Haemodynamically stable : 99M Technetium scan which has an affinity for gastric mucosa (ectopic)
- Unstable : Mesenteric arteriography
Meckel’s diverticulum : Management
1) Surgery
-Wedge excision or formal small bowel resection and anastomosis
Neonatal jaundice : Definition
Jaundice describes the condition of abnormally high levels of bilirubin in the blood
Neonatal jaundice : Physiology
1 . Red blood cells contain unconjugated bilirubin.
2 . RBC breakdown and release of unconjugated bilirubin
3 . Unconjugated bilirubin is conjugated in the liver
4 . Conjugated bilirubin* is excreted in two ways
* via the biliary system into the gastrointestinal tract
* via the urine
Neonatal jaundice : Physiological jaundice
- Foetal cell break down after birth
- Increase bilirubin release } rise in bilirubin
- Less developed liver function : unable to break down excess bilirubin
- Mild yellowing of sclera 2-7 days
- Resolves by 10 days
Neonatal Jaundice : Due to increase bilirubin break down
-
Increased production of bilirubin: } Excess RBC breakdown
* Haemolytic disease of new born : Rhesus incompatibility
* Haemorrhage
* Polycythaemia
* Sepsis or DIC
Neonatal Jaundice : Due to decrease bilirubin clearance
1. Decreased clearance of bilirubin:
* Prematurity : very immature liver
* Breast milk jaundice
-Components of milk inhibit liver breakdown of bilirubin
-Higher risk of dehydration with inadequate feeding - constipation, and more bilirubin absorption
2 . Biliary atresia
3 . Hypothyroidism : lack of T3/T4 inhibits liver enzymes which breakdown bilirubin
4 . Gilbert’s syndrome
Neonatal Jaundice : Prolonged jaundice definition
Jaundice lasts longer than if physiological
* More than 14 days in full term babies
* More than 21 days in premature babies
Neonatal Jaundice : Prolonged jaundice causes
- G6PD deficiency : Genetic disorder when unable to produce G6PD enzyme which protects RBC from oxidative damage
- Hypothyroidism
- Biliary atresia
Neonatal Jaundice : Investigations for diagnosis
- Full blood count and blood film : polycythaemia or anaemia
- Conjugated bilirubin: elevated levels indicate a hepatobiliary cause
- Blood type testing : ABO or rhesus incompatibility
- Direct Coombs Test (direct antiglobulin test) for haemolysis
- Thyroid function, particularly for hypothyroid
- Blood and urine cultures : if infection is suspected. Suspected sepsis needs treatment with antibiotics.
- Glucose-6-phosphate-dehydrogenase: (G6PD) levels for G6PD deficiency
Neonatal Jaundice : Management
- Treatment threshold chart : age and total bilirubin level monitored - tx commence if threshold reached
- Phototherapy with blue light
Neonatal Jaundice : Complication
-
Kernicterus : Bilirubin deposits in the brain causing CNS damage
May cause : Cerebral palsy, learning disability and deafness
Necrotising enterocolitis : Definition
Serious medical condition characterised by inflammation and daage to the tissues of the intestine
* Particularly colon and small intestine
* Commonly affects premature infants with low birth weights
Necrotising enterocolitis : Pathophysiology
- Predominantly affects premature infants (<32 weeks)
- Bacterial infection of intestine : immature gut barrier makes it more permeable
- Inflammation of intestine 2nd to bacterial colonisation
- Intestinal ischaemia —> leads to necrosis of the bowel
* More vulnerable to damage from inflammation and vessels are more susceptible to ischaemia
Necrotising enterocolitis : Incidence
Occurs 2nd - 3rd week of life
Necrotising enterocolitis : Clinical features
- Feeding intolerance
- Abdominal distention
- Blood stools
May acutely progress to : perforation and peritonitis
Necrotising enterocolitis : Investigation
- Abdominal XR may show
* Dilated bowel loops
* Bowel oedema
Abnormal air pockets
* Pnematosis intestinal : gas within the intestinal wall
* Pneumoperitoneal
Necrotising enterocolitis : Risk factors
- Prematurity +++ risk
- Formula feed - reduces protective factors for gut health
- Enteral feeding
Meconium ileus : Definition
Aspirated meconium obstructs the small intestine at the level of terminal ileum
Meconium ileus : Clinical presentation
- Intestinal obstruction within hours after birth
- Billous vomitting during feeds
Meconium ileus : Investigation
Abdominal Xray - soap -bubble sign in distal small intestine where meconium mixes with swallowed air
