Paediatric Gastroenterology Flashcards
Moderate dehydration
6-9% body weight loss Lethargic but irritable Raised HR, normal BP Sunken eyes and Fontainebleau Oliguria usually obvious Skin turgor 1-2 seconds
Severe dehydration
10% body weight loss Infants: drowsy, limp, cold, sweaty, cyanotic limbs, comatose Older children: apprehensive, cold, sweaty, cyanotic limbs Rapid feeble pulse Reduced BP Sunken eyes and fontanelles Skin turgor >2 seconds Deep acidotic breathing
Management of dehydration
Mild:
Oral rehydration solution 45-90mmol/L Na + 90mmol/L glucose to facilitate
Oral or NG tube (if vomiting) over 4 hours
Severe:
IV therapy if circulatory insufficiency
Bolus 20mls/kg normal saline
Once normal perfusion restored, begin ORS
Contraindications for oral rehydration solution
Coma Ileus Intussusception Perforated viscus Malabsorption syndrome Liver disease
IV fluid volume calculations
Maintenance fluids:
0-6m - 120-140mls/kg/day
>6m - first 10kg: 4mL/kg/day, next 10kg: 2ml/kg/day, subsequent >20kg: 1ml/kg/day
+deficit: estimate % dehydration x (BW x 10) in ml/day (divide by 24 for hourly rate)
Resuscitation fluids = normal saline, maintenance fluids = .45% saline + 5% glucose
Causes of gastroenteritis in paediatrics
Viral: rotavirus (50%), adenovirus (5-15%)
Bacterial: campylobacter (5-10%), salmonella, shigella, e. Coli
Parasitic: giardia, cryptosporidium
Differentials for chronic diarrhoea in a child
Toddler's diarrhoea Coeliac disease Giardiasis Spurious/overflow diarrhoea Inflammatory bowel disease Cow's milk protein intolerance Excessive ingestion of fluids Amoeba
Red flags of chronic diarrhoea in a child
Blood in stool Failure to thrive Abnormal stool microscopy - fat globules - red cells - White cells
Mild dehydration
Loss of less than 5% body weight
- dry mucous membranes
- decreased peripheral perfusion (slow cap refill)
- Thirsty
- Alert, restless
What is dermatitis herpetiformis
Coeliac disease
Causes of constipation in children
Functional (95% of healthy children older than 1y) Cow's milk intolerance Coeliac disease CF Lead poisoning Intestinal obstruction IN INFANTS: - Hirschsprung disease - Spinal dysraphism - Sacral teratoma - Infantile botulism
Define functional constipation for a child with developmental age 4y+
At least 2 of the following symptoms occurring for at least 2 months:
- 2 or fewer defecations per week
- at least one episode of foecal incontinence per week
- history of retentive posturing or excessive volitional stool retention (withholding)
- history of painful or hard bowel movements
- presence of large foecal mass in the rectum
- history of large-diameter stools that may obstruct the toilet
History of constipation suggestive of organic disease
Delayed passage of meconium Fever, vomiting, diarrhoea Rectal bleeding Abdominal distenstion Present from birth Ribbon stools (very narrow diameter) Urinary incontinence or bladder disease Weight loss/Poor weight gain Delayed growth Extraintestinal symptoms (esp. neurological) Congenital anomalies or syndrome associated with Hirschsprung disease Family history of HD
When is antibiotic therapy indicated in paediatric gastroenteritis?
ALWAYS in shigella and giardia
LESS THAN 3M olds: salmonella and C. jejuni
Immunocompromised children
Systemically unwell children
Definition of coeliac disease
A small bowel disorder characterised by mucosal inflammation, villous atrophy and hyperplasia, which occur on exposure to dietary gluten and which demonstrate improvement following withdrawal of gluten from the diet
Prevalence of coeliac disease
1 in 70
Clinical features of coeliac disease in a child
Anorexia Weight loss Abdominal distension chronic diarrhoea Growth failure Fatigue and pallor (iron deficiency)
Investigations if suspect coeliac disease
CBE (anaemia)
Iron studies
Autoantibodies (antigliadin, anti endomysial, anti tissue transglutaminase)
Small bowel biopsy: gold standard, must be performed while child still eating gluten, flattening of mucosal villi in small bowel
Management of coeliac dsiease
CELIAC
C: consultation with skilled dietician
E: education about the disease
L: lifelong adherence to gluten-free diet (wheat, rye, barley)
I: identification and treatment of nutritional deficiencies (Fe, folate, Ca, Vit D and B12)
A: access to an advocacy group
C: continuous long term follow up by multi-D team
How to monitor response to gluten free diet in a coeliac
Antibody testing 6m after beginning diet (tissue transglutaminase)
Gluten rechallenge
Causes of non response to gluten free diet in diagnosed coeliacs
Poor compliance or inadvertent gluten intake
Management of GORD in infants
Often difficult to manage, depends on severity and impact on infant:
- Posture: keep upright/head elevated 30deg after feeding
- Food thickening (Karicare, rice cereal, Gaviscon)
- Antacids: mylanta up to 0.5mL/kg (may cause constipation, use sparingly)
- Acid suppression: Ranitidine/omeprazole - 2 week trial of symptom improvement, discontinue if nil
Surgery: Fundoplication if very severe reflux (most commonly in children with CP + scoliosis, difficult flexibility and posture, recurrent aspiration pneumonia)
Clinical features of GORD in infants
Vomiting/regurgitation
Irritability
