Paediatric Gastroenterology Flashcards
State some causes of abdominal pain (excluding adolescent girls)
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
State some red flag symptoms of abdominal pain
Associated features:
- Fever
- Abdominal tenderness
- Bilious vomiting
- Rectal bleeding
- Dysphagia
Additional concerning features:
- Failure to thrive
- Nighttime pain
- Severe chronic diarrhoea
Abdominal migraine - state the following:
- Pathophysiology
- Presentation
- Management
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)
Above what age does faecal incontinence become pathological?
Above 4 years old (usually a sign of chronic constipation)
State some possible causes of encopresis (faecal incontinence) in children
Constipation (overflow incontinence) = most common
Others (most neurological):
- Spina bifida
- Hirschsprung’s disease
- Cerebral palsy
- Learning disability
- Psychosocial stress / abuse
State some lifestyle factors in children that can contribute to constipation
- Poor / low fibre diet
- Poor fluid intake
- Low activity levels
- Psychosocial issues e.g. difficult home or school environment
State some diseases that may lead to constipation (as secondary to the disease) aka. differentials for functional constipation
- Hirschsprung’s disease
- Cystic fibrosis
- Hypothyroidism
- Spinal cord lesions
- Intestinal obstruction
- Anal stenosis or atresia
- Cow’s milk intolerance
- Sexual abuse
State red flag features to ask about with a child presenting with constipation (to help rule out serious underlying conditions)
- 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)
Outline the management steps for paediatric constipation
- 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
Gastro-oesophageal reflux (GOR) - state the following:
- Pathophysiology
- Presentation (including any red flags)
- Investigations
- Management
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
State some underlying causes of paediatric vomiting
- Overfeeding
- Pyloric stenosis (projectile)
- GORD
- Gastritis or gastroenteritis
- Intestinal obstruction
- Appendicitis
- Infections e.g. UTI, meningitis
Older:
- Bulimia
State red flag features to ask about with a child presenting with vomiting (to help rule out serious underlying conditions)
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
Pyloric stenosis - state the following:
- Pathophysiology
- Most common time of presentation
- Presentation (including any red flags)
- Investigations
- Management
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
Gastroenteritis - state the following:
- Pathophysiology
- Presentation and red flag symptoms
- Management
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
State some differentials for loose stools
- Gastroenteritis
- IBS
- IBD
- Lactose intolerance
- Coeliac disease
- Cystic fibrosis (steatorrhoea)
- Toddler’s diarrhoea
- Reaction to medications e.g. antibiotics
State some pathogens involved in paediatric gastroenteritis
- Viral
- Bacterial
Viral:
- Rotavirus
- Norovirus
- Adenovirus (less common - subacute diarrhoea)
Bacterial:
- E coli
- Campylobacter jejuni
State some complications of gastroenteritis
- Lactose intolerance
- IBS
- Reactive arthritis
- Guillain-Barré syndrome
Coeliac disease - state the following:
- Pathophysiology
- Most common age
- Presentation (including any red flags)
- Investigations
- Management
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
State some conditions associated with coeliac disease
- Type 1 diabetes
- Down syndrome
- Thyroid disease
- Autoimmune hepatitis
- Primary biliary sclerosis
- Primary sclerosing cholangitis
- Rheumatoid arthritis
- Addison’s disease
State some long term complications associated with uncontrolled coeliac disease (general and malignancy)
General:
- Vitamin deficiency
- Anaemia
- Osteoporosis
- Failure to thrive in children
Malignancy:
- T cell (enteropathy associated) lymphoma
- Non-Hodgkin’s lymphoma
- Small bowel adenocarcinoma
Inflammatory bowel disease (IBD) - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
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
Biliary atresia - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
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
Intestinal obstruction - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
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
List some potential causes of intestinal obstruction (congenital and aquired)
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
State some changes that could be seen on an x-ray in intestinal obstruction
- Dilated bowel loops (prior to obstruction)
- Collapsed bowel loops (distal to obstruction)
- Absence of air in rectum
Hirschsprung’s disease - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
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
Briefly describe Hirschsprung-associated enterocolitis, how it presents and how it is managed
- 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
Intussusception - state the following:
- Pathophysiology
- Most common age
- Presentation (including any red flags)
- Investigations
- Management
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
State some conditions that have been associated with intussusception
- Viral illness
- Henoch-Schonlein purpura
- Cystic fibrosis
- Intestinal polyps
- Meckel diverticulum
State some complications of intussusception
- Intestinal obstruction
- Gangrenous bowel
- Perforated bowel
- Death
State some differentials for intussusception
- Volvulus
- Hirschsprung’s disease
- Colic
- Gastroenteritis
- Appendicitis
- Pyloric stenosis
- Testicular torsion
- UTI
Appendicitis - state the following:
- Pathophysiology
- Most common age
- Presentation (including any red flags)
- Investigations
- Management
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)
- Prophylactic antibiotics
- Laparoscopic surgery to remove appendix (antibiotics given 1 dose before surgery and 2 doses after)
- In some high-risk cases IV abx may be trialled but high failure rate
- If appendiceal mass, initially treat with antibiotics and appendectomy 6-8 weeks later
State some potential complications of appendicetomy
- Chance of finding/removing a non-inflammed appendix
- Damage to local structures (bowel, bladder)
- Infection
- Bleeding
- Anaesthetic risks e.g. VTE
State some differentials for appendicitis
Gastro:
- Mesenteric adenitis
- Meckel’s diverticulitis
- Intussusception
- Gastroenteritis
- Cholecystitis
- IBD
- PUD
Urinary:
- Right renal stone
- UTI / pyelonephritis
Female:
- Ectopic pregnancy
- Ovarian torsion
- PID
- Mittelschmerz
Volvulus - state the following:
- Pathophysiology
- Most common age
- Presentation
- Investigations
- Management
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)
State the 2 categories of peritonitis
- Primary (spontaneous) peritonitis
- Secondary peritonitis
State some causes of primary (spontaneous) peritonitis in children
Occurs secondary to ascites
- Liver disease
- Kidney disease
State some causes of secondary peritonitis in children
- Ruptured appendix
- Perforated stomach ulcer / gallbladder / pancreas
- Perforated intestines e.g. Crohn’s disease
- Abdominal injury / surgery
Acute liver failure in children - state the following:
- Pathophysiology
- Presentation (including any red flags)
- Investigations
- Management
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
State the most common causes of liver failure in the following paediatric age groups
- Overall
- Neonates
- Older children
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)
Hepatitis B in children - state the following:
- Pathophysiology
- Who requires investigation
- Management
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
Hepatitis C in children - state the following:
- Pathophysiology
- Management
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
State the prognosis for children exposed to Hepatitis B for the following age groups
- Neonates
- Children under 5
- Adolescents
Neonates: 90% develop
Children under 5: 30% develop
Adolescents: 10% develop
State the % of babies who are affected by hep C during pregnancy
5-15% babies contract Hep C during pregnancy
*Antivirals are not recommended in pregnancy
What database should you consult for accidental poisoning
ToxBase - clinical toxicological database of the UK National Poisons Information Service
Outline how poisoning of unknown origin should be managed
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
