Paediatric Gastroenterology Flashcards
Medical Causes of Abdominal Pain
Other causes need to be excluded before diagnosing non-organic pain:
Constipation is also very common
Urinary tract infection
Coeliac disease
Inflammatory bowel disease
Irritable bowel syndrome
Mesenteric adenitis
Abdominal migraine
Pyelonephritis
Henoch-Schonlein purpura
Tonsilitis
Diabetic ketoacidosis
Infantile colic
There are addition causes in adolescent girls:
Dysmenorrhea (period pain)
Mittelschmerz (ovulation pain)
Ectopic pregnancy
Pelvic inflammatory disease
Ovarian torsion
Pregnancy
Surgical Causes of Abdominal Pain
Appendicitis causes central abdominal pain spreading to the right iliac fossa
Intussusception causes colicky non-specific abdominal pain with redcurrant jelly stools
Bowel obstruction causes pain, distention, absolute constipation and vomiting
Testicular torsion causes sudden onset, unilateral testicular pain, nausea and vomiting
Red Flags for Serious Abdominal Pain
Persistent or bilious vomiting
Severe chronic diarrhoea
Fever
Rectal bleeding
Weight loss or faltering growth
Dysphagia (difficulty swallowing)
Nighttime pain
Abdominal tenderness
Initial investigations that may indicate the pathology:
Anaemia can indicate inflammatory bowel disease or coeliac disease
Raised inflammatory markers (ESR and CRP) can indicate inflammatory bowel disease
Raised anti-TTG or anti-EMA antibodies indicates coeliac disease
Raised faecal calprotectin indicates inflammatory bowel disease
Positive urine dipstick indicates a urinary tract infection
Recurrent Abdominal Pain
A diagnosis of recurrent abdominal pain is made when a child presents with repeated episodes of abdominal pain without an identifiable underlying cause. The pain is described as non-organic or functional. This is common and can lead to psychosocial problems, such as missed days at school and parental anxiety. There is overlap between the diagnoses of recurrent abdominal pain, abdominal migraine, irritable bowel syndrome and functional abdominal pain.
Recurrent abdominal pain often corresponds to stressful life events, such as loss of a relative or bullying. The leading theory for the cause is increased sensitivity and inappropriate pain signals from the visceral nerves (the nerves in the gut) in response to normal stimuli.
Management involves careful explanation and reassurance. Measures that can help manage the pain are:
Distracting the child from the pain with other activities or interests
Encourage parents not to ask about or focus on the pain
Advice about sleep, regular meals, healthy balanced diet, staying hydrated, exercise and reducing stress
Probiotic supplements may help symptoms of irritable bowel syndrome
Avoid NSAIDs such as ibuprofen
Address psychosocial triggers and exacerbating factors
Support from a school counsellor or child psychologist
Abdominal migraine
Children are more likely than adults to suffer with a condition called abdominal migraine. This may occur in young children before they develop traditional migraines as they get older. Abdominal migraine presents with episodes of central abdominal pain lasting more than 1 hour. Examination will be normal.
There may be associated:
Nausea and vomiting
Anorexia
Pallor
Headache
Photophobia
Aura
Managing abdominal migraine
Management of abdominal migraine is similar to migraine in adults. Careful explanation and education is important. It involves treating acute attacks and preventative measures. Preventative medications are initiated by a specialist.
Treating the acute attack:
Low stimulus environment (quiet, dark room)
Paracetamol
Ibuprofen
Sumatriptan
Preventative medications:
Pizotifen, a serotonin agonist
Propranolol, a non-selective beta blocker
Cyproheptadine, an antihistamine
Flunarazine, a calcium channel blocker
Pizotifen is the main preventative medication to remember for abdominal migraine. It needs to be withdrawn slowly when stopping as it is associated with withdrawal symptoms such as depression, anxiety, poor sleep and tremor.
Constipation
Constipation in children is a very common problem in paediatrics. Most cases of constipation can be described as idiopathic constipation or functional constipation, meaning there is not a significant underlying cause other than simple lifestyle factors. It is important to think about possible secondary causes of constipation, such as Hirschsprung’s disease, cystic fibrosis or hypothyroidism.
Presentation of constipation
How often someone opens their bowels varies between individuals. This is even more variable in breast-fed babies, which can have as little as one stool a week. Someone opening their bowels daily may be constipated, whereas someone opening their bowels twice a week may not, if that is normal for them.
Typical features in the history and examination that suggest constipation are:
Less than 3 stools a week
Hard stools that are difficult to pass
Rabbit dropping stools
Straining and painful passages of stools
Abdominal pain
Holding an abnormal posture, referred to as retentive posturing
Rectal bleeding associated with hard stools
Faecal impaction causing overflow soiling, with incontinence of particularly loose smelly stools
Hard stools may be palpable in abdomen
Loss of the sensation of the need to open the bowels
Encopresis
Encopresis is the term for faecal incontinence. This is not considered pathological until 4 years of age. It is usually a sign of chronic constipation where the rectum becomes stretched and looses sensation. Large hard stools remain in the rectum and only loose stools are able to bypass the blockage and leak out, causing soiling.
Other rarer causes of encopresis include:
Spina bifida
Hirschprung’s disease
Cerebral palsy
Learning disability
Psychosocial stress
Abuse
Lifestyle factors and constipation
There are a number of lifestyle factors that can contribute to the development and continuation of constipation:
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 (always keep safeguarding in mind)
Desensitisation of the Rectum
Often patients develop a habit of not opening their bowels when they need to and ignoring the sensation of a full rectum. Over time they loose the sensation of needing to open their bowels, and they open their bowels even less frequently. They start to retain faeces in their rectum. This leads to faecal impaction, which is where a large, hard stool blocks the rectum. Over time the rectum stretches as it fills with more and more faeces. This leads to further desensitisation of the rectum. The longer this goes on, the more difficult it is to treat the constipation and reverse the problem.
Secondary causes of constipation
Hirschsprung’s disease
Cystic fibrosis (particularly meconium ileus)
Hypothyroidism
Spinal cord lesions
Sexual abuse
Intestinal obstruction
Anal stenosis
Cows milk intolerance
Red flags for constipation
Red flags are things in the history or examination that should make you think about serious underlying conditions that may be causing the constipation. These should prompt further investigations and referral to a specialist:
Not passing meconium within 48 hours of birth (cystic fibrosis or Hirschsprung’s disease)
Neurological signs or symptoms, particularly in the lower limbs (cerebral palsy or spinal cord lesion)
Vomiting (intestinal obstruction or Hirschsprung’s disease)
Ribbon stool (anal stenosis)
Abnormal anus (anal stenosis, inflammatory bowel disease or sexual abuse)
Abnormal lower back or buttocks (spina bifida, spinal cord lesion or sacral agenesis)
Failure to thrive (coeliac disease, hypothyroidism or safeguarding)
Acute severe abdominal pain and bloating (obstruction or intussusception)
Complications of constipation
Pain
Reduced sensation
Anal fissures
Haemorrhoids
Overflow and soiling
Psychosocial morbidity
Managing constipation
A diagnosis of idiopathic constipation can be made without investigations, provided red flags are considered. It is important to provide adequate explanation of the diagnosis and management as well as reassure parents about the absence of concerning underlying causes. Explain that treating constipation can be a prolonged process, potentially lasting months.
NICE clinical knowledge summaries recommend:
Correct any reversible contributing factors, recommend a high fibre diet and good hydration
Start laxatives (movicol is first line)
Faecal impaction may require a disimpaction regimen with high doses of laxatives at first
Encourage and praise visiting the toilet. This could involve scheduling visits, a bowel diary and star charts.
Laxatives should be continued long term and slowly weaned off as the child develops a normal, regular bowel habit.
Gastro-oesophageal reflux
Gastro-oesophageal reflux is where contents from the stomach reflux through the lower oesophageal sphincter into the oesophagus, throat and mouth.
In babies there is immaturity of the lower oesophageal sphincter, allowing stomach contents to easily reflux into the oesophagus. It is normal for a baby to reflux feeds, and provided there is normal growth and the baby is otherwise well this is not a problem, however it can be upsetting for parents. This usually improves as they grow and 90% of infants stop having reflux by 1 year.
Presentation of gastro-oesophageal reflux
It is normal for babies to have some reflux after larger feeds. It becomes more troublesome when this causes them to become distressed. Signs of problematic reflux include:
Chronic cough
Hoarse cry
Distress, crying or unsettled after feeding
Reluctance to feed
Pneumonia
Poor weight gain
Children over one year may experience similar symptoms to adults, with heartburn, acid regurgitation, retrosternal or epigastric pain, bloating and nocturnal cough.
Causes of vomiting
Vomiting is very non-specific and is often not indicative of underlying pathology. Some of the possible causes of vomiting include:
Overfeeding
Gastro-oesophageal reflux
Pyloric stenosis (projective vomiting)
Gastritis or gastroenteritis
Appendicitis
Infections such as UTI, tonsillitis or meningitis
Intestinal obstruction
Bulimia
Red flags of vomiting
Certain features in the history should make you think about serious underlying problems:
Not keeping down any feed (pyloric stenosis or intestinal obstruction)
Projectile or forceful vomiting (pyloric stenosis or intestinal obstruction)
Bile stained vomit (intestinal obstruction)
Haematemesis or melaena (peptic ulcer, oesophagitis or varices)
Abdominal distention (intestinal obstruction)
Reduced consciousness, bulging fontanelle or neurological signs (meningitis or raised intracranial pressure)
Respiratory symptoms (aspiration and infection)
Blood in the stools (gastroenteritis or cows milk protein allergy)
Signs of infection (pneumonia, UTI, tonsillitis, otitis or meningitis)
Rash, angioedema and other signs of allergy (cows milk protein allergy)
Apnoeas are a concerning feature and may indicate serious underlying pathology and need urgent assessment
Managing gastro-oesophageal reflux
In simple cases some explanation, reassurance and practical advice is all that is needed. Advise:
Small, frequent meals
Burping regularly to help milk settle
Not over-feeding
Keep the baby upright after feeding (i.e. not lying flat)
More problematic cases can justify treatment with
Gaviscon mixed with feeds
Thickened milk or formula (specific anti-reflux formulas are available)
Proton pump inhibitors (e.g., omeprazole) where other methods are inadequate
Rarely in severe cases they may need further investigation with a barium meal and endoscopy. Surgical fundoplication can be considered in very severe cases, however this is very rarely required or performed.
Sandifer’s Syndrome
This is a rare condition causing brief episodes of abnormal movements associated with gastro-oesophageal reflux in infants. The infants are usually neurologically normal. The key features are:
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
The condition tends to resolve as the reflux is treated or improves. Generally the outcome is good. It is worth referring patients with these symptoms to a specialist for assessment, as the differential diagnosis includes more serious conditions such as infantile spasms (West syndrome) and seizures.
Features of pyloric stenosis
The pyloric sphincter is a ring of smooth muscle that forms the canal between the stomach and the duodenum. Hypertrophy (thickening) and therefore narrowing of the pylorus is called pyloric stenosis. This prevents food traveling from the stomach to the duodenum as normal.
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, out of the mouth and across the room. This is called “projectile vomiting”.
Features
Pyloric stenosis typically presents in the first few weeks of life, with a hungry baby that is thin, pale and generally failing to thrive. The classic description of vomiting you should remember for your exams is “projectile vomiting”.
If examined after feeding, often the peristalsis can be seen by observing the abdomen. A firm, round mass can be felt in the upper abdomen that “feels like a large olive”. This is caused by the hypertrophic muscle of the pylorus.
Blood gas analysis will show a hypochloric (low chloride) metabolic alkalosis as the baby is vomiting the hydrochloric acid from the stomach. This is a common data interpretation question in exams, so worth remembering.
Managing pyloric stenosis
Diagnosis is made using an abdominal ultrasound to visualise the thickened pylorus.
Treatment involves a laparoscopic pyloromyotomy (known as “Ramstedt’s operation“). 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. Prognosis is excellent following the operation.
Gastroenteritis
Acute gastritis is inflammation of the stomach and presents with nausea and vomiting. Enteritis is inflammation of the intestines and presents with diarrhoea. Gastroenteritis is inflammation all the way from the stomach to the intestines and presents with nausea, vomiting and diarrhoea.
Gastroenteritis is a very common condition in children. The most common cause of gastroenteritis is viral. It is very easily spread and patients presenting with gastroenteritis often have an affected family member or contact.
It is essential to isolate the patient in any healthcare environment, such as a paediatric assessment unit or hospital ward, as they can easily spread it to other patients.
Dehydration is the main concern. The key to management is establishing whether they are able to keep themselves hydrated or whether they need admission for IV fluids. Antibiotics are generally not recommended or required. Most children make a full recovery with simple supportive management, but beware gastroenteritis can potentially be fatal, especially in very young or vulnerable children with other health conditions.
Differential Diagnosis of Diarrhoea
Loose stools are a common complaint and not all cases are caused by gastroenteritis. Stools from normal babies can vary from loose stools several times a day to one stool per week. Steatorrhoea means greasy stools with excessive fat content. This suggests a problem with digesting fats, such as pancreatic insufficiency (think about cystic fibrosis).
Key conditions to think about in patients with loose stools are:
Infection (gastroenteritis)
Inflammatory bowel disease
Lactose intolerance
Coeliac disease
Cystic fibrosis
Toddler’s diarrhoea
Irritable bowel syndrome
Medications (e.g. antibiotics)
Viral gastroenteritis
Viral gastroenteritis is common. It is highly contagious. Common causes are:
Rotavirus
Norovirus
Adenovirus is a less common cause and presents with a more subacute diarrhoea.
E. coli
Escherichia coli (E. coli) is a normal intestinal bacteria. Only certain strains cause gastroenteritis. It is spread through contact with infected faeces, unwashed salads or contaminated water.
E. coli 0157 produces the Shiga toxin. This causes abdominal cramps, bloody diarrhoea and vomiting. The Shiga toxin destroys blood cells and leads to haemolytic uraemic syndrome (HUS).
The use of antibiotics increases the risk of haemolytic uraemic syndrome, therefore antibiotics should be avoided if E. coli gastroenteritis is considered.
Campylobacter Jejuni
Campylobacter is a common cause of travellers diarrhoea. It is the most common bacterial cause of gastroenteritis worldwide. Campylobacter means “curved bacteria”. It is a gram negative bacteria that has a curved or spiral shape. It is spread by:
Raw or improperly cooked poultry
Untreated water
Unpasteurised milk
Incubation is usually 2 to 5 days. Symptoms resolve after 3 to 6 days. Symptoms are:
Abdominal cramps
Diarrhoea often with blood
Vomiting
Fever
Antibiotics can be considered after isolating the organism where patients have severe symptoms or other risk factors such as HIV or heart failure. Popular antibiotic choices are azithromycin or ciprofloxacin.
Shigella
Shigella is spread by faeces contaminating drinking water, swimming pools and food. The incubation period is 1 to 2 days and symptoms usually resolve within 1 week without treatment. It causes bloody diarrhoea, abdominal cramps and fever. Shigella can produce the Shiga toxin and cause haemolytic uraemic syndrome. Treatment of severe cases is with azithromycin or ciprofloxacin.
