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Year 4 - 3. Paediatrics > Paediatric Gastroenterology > Flashcards

Paediatric Gastroenterology Flashcards

1
Q

State some causes of abdominal pain (excluding adolescent girls)

A

GI:
- Constipation
- IBS
- IBD
- Coeliac disease
- Lactose intolerance
- Mesenteric adenitis
- Abdominal migraine
- Appendicitis
- Intusucception
- Bowel obstruction

Urinary:
- UTI / pyelonephritis
- DKA

+ Testicular torsion
+ Henoch Schonlein purpura
+ tonsilitis

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2
Q

State some red flag symptoms of abdominal pain

A

Associated features:
- Fever
- Abdominal tenderness
- Bilious vomiting
- Rectal bleeding
- Dysphagia

Additional concerning features:
- Failure to thrive
- Nighttime pain
- Severe chronic diarrhoea

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3
Q

Abdominal migraine - state the following:
- Pathophysiology
- Presentation
- Management

A

Pathophysiology:
- Functional abdominal pain, with episodes that last for > 1 hour, with normal examination
- Often occurs prior to development of traditional migraines

Presentation:
- Episodes of abdominal pain that last for > 1 hour
- May have associated symptoms e.g. headache, aura, photophobia, N&V and pallor

Management:
- Acute attacks: dark room, Paracetamol/Ibuprofen and Sumitriptan
- Prevention with Pizotifen (Serotonin agonist)

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4
Q

Above what age does faecal incontinence become pathological?

A

Above 4 years old (usually a sign of chronic constipation)

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5
Q

State some possible causes of encopresis (faecal incontinence) in children

A

Constipation (overflow incontinence) = most common

Others (most neurological):
- Spina bifida
- Hirschsprung’s disease
- Cerebral palsy
- Learning disability
- Psychosocial stress / abuse

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6
Q

State some lifestyle factors in children that can contribute to constipation

A
  • Poor / low fibre diet
  • Poor fluid intake
  • Low activity levels
  • Psychosocial issues e.g. difficult home or school environment
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7
Q

State some diseases that may lead to constipation (as secondary to the disease) aka. differentials for functional constipation

A
  • Hirschsprung’s disease
  • Cystic fibrosis
  • Hypothyroidism
  • Spinal cord lesions
  • Intestinal obstruction
  • Anal stenosis or atresia
  • Cow’s milk intolerance
  • Sexual abuse
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8
Q

State red flag features to ask about with a child presenting with constipation (to help rule out serious underlying conditions)

A
  • Age appropriate growth and development (coeliac disease, hypothyroidism, abuse)
  • Any neurological symptoms
  • Vomiting (intestinal obstruction, Hirschsprung’s disease)
  • Acute abdominal pain and bleeding (intestinal obstruction, intussusception)
  • Ribbon stool (anal stenosis)
  • Abnormal anus (anal stenosis, IBD, sexual abuse)
  • Abnormal lower back or buttocks (spina bifida, spinal cord issue)
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9
Q

Outline the management steps for paediatric constipation

A
  • Correct any contributing factors e.g. good fluid intake, fibre intake, toilet routine
  • Laxatives e.g. Movicol (first line)
  • May require disimpaction regime with high dose laxatives
  • Encourage good toileting routines
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10
Q

Gastro-oesophageal reflux (GOR) - state the following:
- Pathophysiology
- Presentation (including any red flags)
- Investigations
- Management

A

Pathophysiology:
- Reflux of stomach contents, through the lower oesophageal sphincter
- More common in babies due to immaturity of the lower oesophageal sphincter
- Resolves in 90% of cases by 1 year old

Presentation:
- Reluctance to feed
- Distress or unsettled after feeding
- Poor weight gain
- Chronic cough
- Hoarse cry
- Pneumonia

Investigations:
- Consider investigations if suspecting other underlying cause

Management:
- Slight changes to feeding e.g. small feeds / avoid overfeeding, burping regularly and keep baby upright after feeding
- Gaviscon with feeds
- Thickened feeds
- Ranitidine

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11
Q

State some underlying causes of paediatric vomiting

A
  • Overfeeding
  • Pyloric stenosis (projectile)
  • GORD
  • Gastritis or gastroenteritis
  • Intestinal obstruction
  • Appendicitis
  • Infections e.g. UTI, meningitis

Older:
- Bulimia

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12
Q

State red flag features to ask about with a child presenting with vomiting (to help rule out serious underlying conditions)

A

GI:
- Projectile vomiting / not keeping down any food (pyloric stenosis, intestinal obstruction)
- Abdominal distension (intestinal obstruction)
- Bilious vomiting (intestinal obstruction)
- Haematemesis or melaena (upper GI bleed)
- Haematochezia
- Rash, angioedema (allergy)

Neurological:
- Meningitis symptoms e.g. bulging fontanelle, reduced consciousness (meningitis, raised ICP)

Respiratory:
- Respiratory symptoms e.g. chronic cough (aspiration/infection)
- Apnoea

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13
Q

Pyloric stenosis - state the following:
- Pathophysiology
- Most common time of presentation
- Presentation (including any red flags)
- Investigations
- Management

A

Pathophysiology:
- Hypertrophy of the pyloric muscle leads to narrowing of the pylorus into the duodenum

Most common time of presentation:
- 4-6 weeks after birth

Presentation:
- Projectile vomiting
- Baby failing to thrive but hungry
- ‘Large olive’ may be palpable (hypertrophic pyloric muscle)
- May be able to feel peristalsis
- Blood gas may show metabolic alkalosis (low chloride)

Investigations:
- Abdominal ultrasound shows thickened pyloric sphincter

Management:
- Laparoscopic pyloromyotomy or ‘Ramstedt’s operation’
- Incision in the smooth muscle to widen the canal, prognosis is normally excellent

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14
Q

Gastroenteritis - state the following:
- Pathophysiology
- Presentation and red flag symptoms
- Management

A

Pathophysiology:
- Inflammation of the entire GI tract
- Gastritis = stomach inflammation
- Enteritis = intestine inflammation

Presentation:
- Vomiting
- Sudden onset diarrhoea
- Abdominal pain/cramps
- Mild fever
Red flag symptoms: hypotension, tachycardia, cold peripheries, mottled colour, decreased consciousness,

Management:
- Isolation and barrier nursing
- Child stay off school until 48 hours after symptoms completely resolve
- Ensure hydration e.g. fluid challenge

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15
Q

State some differentials for loose stools

A
  • Gastroenteritis
  • IBS
  • IBD
  • Lactose intolerance
  • Coeliac disease
  • Cystic fibrosis (steatorrhoea)
  • Toddler’s diarrhoea
  • Reaction to medications e.g. antibiotics
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16
Q

State some pathogens involved in paediatric gastroenteritis
- Viral
- Bacterial

A

Viral:
- Rotavirus
- Norovirus
- Adenovirus (less common - subacute diarrhoea)

Bacterial:
- E coli
- Campylobacter jejuni

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17
Q

State some complications of gastroenteritis

A
  • Lactose intolerance
  • IBS
  • Reactive arthritis
  • Guillain-Barré syndrome
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18
Q

Coeliac disease - state the following:
- Pathophysiology
- Most common age
- Presentation (including any red flags)
- Investigations
- Management

A

Pathophysiology:
- T cell-mediated immune disorder, where exposure to gluten (gliadin) causes autoantibodies to attack epithelial cells
- This leads to inflammation in the small bowel (jejunum) and atrophy of the villi
- Anti-TTG and anti-EMA autoantibodies (levels rise in correlation with disease state)

Most common age:
- Most common presentation at 9-24 months

Presentation:
- Failure to thrive / weight loss
- Fatigue
- Abdominal pain or distension
- Steatorrhea / diarhorrea
- Anorexia
- Mouth ulcers
- May have associated behavioural issues
Extraintestinal manifestation
- Dermatitis herpetiformis
- Osteoporosis
- Short stature
- Iron- deficient anaemia (unreactive to oral iron)
- Arthritis
- Peripheral neuropathy, epilepsy, ataxia

Investigations:
- Anti-TTG and EMA serology (need to be eating gluten still and test for IgA levels)
- If positive serology, endoscopic duodenual biopsy

Management:
- Lifelong gluten-free diet

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19
Q

State some conditions associated with coeliac disease

A
  • Type 1 diabetes
  • Down syndrome
  • Thyroid disease
  • Autoimmune hepatitis
  • Primary biliary sclerosis
  • Primary sclerosing cholangitis
  • Rheumatoid arthritis
  • Addison’s disease
20
Q

State some long term complications associated with uncontrolled coeliac disease (general and malignancy)

A

General:
- Vitamin deficiency
- Anaemia
- Osteoporosis
- Failure to thrive in children

Malignancy:
- T cell (enteropathy associated) lymphoma
- Non-Hodgkin’s lymphoma
- Small bowel adenocarcinoma

21
Q

Inflammatory bowel disease (IBD) - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management

A

Pathophysiology:
- Inflammation of the bowel, autoimmune condition

Presentation:
- Abdominal pain
- Diarrhoea (bloody/mucus) with increased urgency
- May have extra intestinal manifestations

Investigations:
- Faecal calprotectin
- Stool culture if suspecting infectious cause
- Endoscopy and biopsy
- Imaging (ultrasound, CT or MRI) can visualise complications of disease

Management:
- Induce remission (Crohn’s = oral Prednisolone, UC = oral Mesalazine)
- Maintain remission

22
Q

Biliary atresia - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management

A

Pathophysiology:
- Abnormality in the bile duct, either narrowing or absence
- Leads to reduced transport of bile from the liver to the small bowel
- Leads to overflow of conjugated bile and jaundice

Presentation:
- Significant jaundice in newborn (lasting > 14 days in preterm and > 21 days in term babies)
- High levels / proportion of conjugated bilirubin

Investigations:
- Blood test showing high levels / proportion of conjugated bilirubin

Management:
- Surgery!! Kasai Portoenterostomy, connecting duodenum directly to the liver
- However most cases will eventually require a liver transplant

23
Q

Intestinal obstruction - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management

A

Pathophysiology:
- Physical obstruction in the bowel, which prevents passage of faeces through the bowel
- The blockage creates a back-pressure through the system, leading to vomiting and absolute constipation

Presentation:
- Persistent vomiting, may be bilious
- Absolute constipation
- Abdominal pain and distention
- Abnormal bowel sounds (high pitched / tinkling early, absent later)

Investigations:
- Abdominal x-ray

Management:
- Referral to paediatric surgical unit
- Nil by mouth
- NG tube insertion
- IV fluids
- Investigate and manage underlying cause

24
Q

List some potential causes of intestinal obstruction (congenital and aquired)

A

Congenital issues:
- Hirschsprung’s disease
- Oesophageal atresia
- Duodenal atresia
- Imperforate anus
- Meconium ileus (cystic fibrosis)

Acquired:
- Intussusception
- Malrotation of intestines with a volvulus
- Strangulated hernia

25
Q

State some changes that could be seen on an x-ray in intestinal obstruction

A
  • Dilated bowel loops (prior to obstruction)
  • Collapsed bowel loops (distal to obstruction)
  • Absence of air in rectum
26
Q

Hirschsprung’s disease - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management

A

Pathophysiology:
- Absence of parasympathetic ganglion nerve cells (of the Auerbach’s plexus) in the distal bowel and rectum
- Caused by the parasympathetic ganglion nerve cells failure to migrate to distal colon, from where they start higher up
- Leads to inability of the bowel to produce peristalsis and inability to relax, leading to constriction and obstruction
- Length of colon which lacks innervation varies

Presentation:
Either acute intestinal obstruction shortly after birth or gradual development symptoms of following
- Explosive diarrhoea after DRE exam = highly suggestive of Hirschsprung’s
- Delay in passing meconium
- Chronic constipation
- Abdominal pain and distension
- Failure to thrive / poor weight gain
- Vomiting

Investigations:
- Rectal suction biopsy and histology (shows absence of parasympathetic ganglion cells in affected tissue)

Management:
- Definitive management: removal of aganglionic tissue

27
Q

Briefly describe Hirschsprung-associated enterocolitis, how it presents and how it is managed

A
  • Inflammation and obstruction of the bowel
  • Occurs in 20% of neonates with Hirschsprung’s

Presentation:
- Presents within first 2-4 weeks of birth
- Fever, abdominal distention, blood in stool and features of sepsis

Management:
- IV antibiotics
- IV fluid resuscitation
- NG tube to decompress obstruction

28
Q

Intussusception - state the following:
- Pathophysiology
- Most common age
- Presentation (including any red flags)
- Investigations
- Management

A

Pathophysiology:
- Occurs when the proximal bowel ‘telescopes’ into the distal section
- The folded section increases the thickness of the bowel overall, but actually reduces the size of the lumen, leading to features of bowel obstruction
- Often occurs when a viral illness is present

Most common age:
- 6 months to 2 years
- More common in boys

Presentation:
- Recurrent jelly stool (blood and mucus)
- Colicky abdominal pain (severe)
- ‘Sausage shaped’ RUQ mass
- Features of obstruction e.g. abdominal distension, vomiting and constipation
- Pale, lethargic and generally unwell

Investigations:
- Abdominal ultrasound scan (target sign)
- Air contrast enema

Management:
- Therapeutic enema if child is stable (contrast, water or air used)
- Surgical reduction if enema unsuccessful / child is unstable
- Surgical resection if bowel becomes perforated or gangrenous

29
Q

State some conditions that have been associated with intussusception

A
  • Viral illness
  • Henoch-Schonlein purpura
  • Cystic fibrosis
  • Intestinal polyps
  • Meckel diverticulum
30
Q

State some complications of intussusception

A
  • Intestinal obstruction
  • Gangrenous bowel
  • Perforated bowel
  • Death
31
Q

State some differentials for intussusception

A
  • Volvulus
  • Hirschsprung’s disease
  • Colic
  • Gastroenteritis
  • Appendicitis
  • Pyloric stenosis
  • Testicular torsion
  • UTI
32
Q

Appendicitis - state the following:
- Pathophysiology
- Most common age
- Presentation (including any red flags)
- Investigations
- Management

A

Pathophysiology:
- Inflammation of the appendix
- Caused by blockage of appendix opening, from faecolith, lymph node swelling or foreign body obstruction
- High risk of gangrene and rupture

Most common age:
- 10 to 20 years

Presentation:
- Dull central umbilical pain, which migrates to RIF
- Tenderness in McBurney’s point (2/3 of way from umbilicus to ASIS)
- Rovsing’s sign
- Anorexia
- N&V
- If perforation, guarding, rebound and percussion tenderness

Investigations:
- Generally based on clinical presentation and raised inflammatory markers
- Can use a CT scan to confirm if other diagnosis is more likely
- Can use USS to rule out other pathology in females
- Diagnostic laparoscopy if clinical presentation suggestive but low markers

Management:
- Emergency admission under surgical team (adult surgeons if >10 years)
- Laparoscopic surgery to remove appendix

33
Q

State some potential complications of appendicetomy

A
  • Chance of finding/removing a non-inflammed appendix
  • Damage to local structures (bowel, bladder)
  • Infection
  • Bleeding
  • Anaesthetic risks e.g. VTE
34
Q

State some differentials for appendicitis

A

Gastro:
- Mesenteric adenitis
- Meckel’s diverticulitis
- Intussusception
- Gastroenteritis
- Cholecystitis
- IBD
- PUD

Urinary:
- Right renal stone
- UTI / pyelonephritis

Female:
- Ectopic pregnancy
- Ovarian torsion
- PID
- Mittelschmerz

35
Q

Volvulus - state the following:
- Pathophysiology
- Most common age
- Presentation
- Investigations
- Management

A

Pathophysiology:
- Most commonly occurs in children with congenital intestinal malrotation (which generally presents within first few weeks of life)

Presentation:
- Bilious vomiting
- Upper abdominal distension
- Abdominal tenderness
- Haemodynamic deterioration

Investigations:
- Abdominal x-ray
- Upper GI motility scans

Management:
- IV fluids
- Ladd’s operation to unwind the volvulus (anticlockwise)

36
Q

State the 2 categories of peritonitis

A
  1. Primary (spontaneous) peritonitis
  2. Secondary peritonitis
37
Q

State some causes of primary (spontaneous) peritonitis in children

A

Occurs secondary to ascites

  • Liver disease
  • Kidney disease
38
Q

State some causes of secondary peritonitis in children

A
  • Ruptured appendix
  • Perforated stomach ulcer / gallbladder / pancreas
  • Perforated intestines e.g. Crohn’s disease
  • Abdominal injury / surgery
39
Q

Acute liver failure in children - state the following:
- Pathophysiology
- Presentation (including any red flags)
- Investigations
- Management

A

Pathophysiology:
- Acute failure of the liver
- Typically rare in children
- Defined by biochemical evidence of liver failure with coagulopathy

Presentation:
Varies depending on age and cause of failure
- Jaundice
- Easily bleeding or bruising
- Oedema
- Abdominal pain
- Enlarged liver or spleen
- Irritability / altered mental state

Investigations:
- Group and save
- Urine toxicology screen
- Immunology screen
- Blood culture
- Hepatitis serology

Management:
- Regular monitoring
- IV fluids
- Daily IV vitamin K
- Ranitidine
- Lactulose

40
Q

State the most common causes of liver failure in the following paediatric age groups
- Overall
- Neonates
- Older children

A

Overall:
- Viral hepatitis

Neonates:
- Herpes simplex
- Metabolic or ischaemic damage

Older children:
- Infections e.g. measles, EBV
- Medications / toxins e.g. Paracetamol, anticonvulsants
- Underlying metabolic / autoimmune conditions e.g. Wilson’s disease
- Ischaemia e.g. Budd Chiari
- Malignancy (rare)

41
Q

Hepatitis B in children - state the following:
- Pathophysiology
- Who requires investigation
- Management

A

Pathophysiology:
- DNA virus
- Can be transmitted vertically during pregnancy or birth, or during direct contact with bodily fluid

Who requires investigation:
- Children born to hep B positive mothers
- Migrants from endemic areas
- Close contacts of hep B positive

Management:
- If asymptomatic, requires no treatment
- If symptomatic, consider use of antivirals

42
Q

Hepatitis C in children - state the following:
- Pathophysiology
- Management

A

Pathophysiology:
- RNA virus
- Can be transmitted vertically during pregnancy or birth (only small %), or during direct contact with bodily fluid

Management:
- Babies tested for hep C at 18 months
- Children tend to clear infection
- Mothers can breastfeed (unless cracked nipples / broken skin)
- Treatment typically delayed until adultgood

43
Q

State the prognosis for children exposed to Hepatitis B for the following age groups
- Neonates
- Children under 5
- Adolescents

A

Neonates: 90% develop

Children under 5: 30% develop

Adolescents: 10% develop

44
Q

State the % of babies who are affected by hep C during pregnancy

A

5-15% babies contract Hep C during pregnancy

*Antivirals are not recommended in pregnancy

45
Q

What database should you consult for accidental poisoning

A

ToxBase - clinical toxicological database of the UK National Poisons Information Service

46
Q

Outline how poisoning of unknown origin should be managed

A

A-E approach
- Secure airway
- Correct any drop in BP
- ECG to check for any arrhythmias
- Monitor temperate for hypothermia

  • Give activated charcoal if ingestion was < 1 hour ago
  • Consult ToxBase
  • Urine toxicology screen to assess substance ingested
  • May need to use stomach pumping in rare cases

Year 4 - 3. Paediatrics (16 decks)

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