Paediatric gastroenterology Flashcards
Causes of vomiting
Vomiting in infants
- Common chronic causes are gastro-oesophageal reflux and feeding problems, e.g. force-feeding or overfeeding
- If transient, with other symptoms, e.g. fever, diarrhoea or runny nose and cough, most likely to be gastroenteritis or respiratory tract infection, but consider urine infection and meningitis
- If projectile at 2–7 weeks of age, exclude pyloric stenosis
- If bile stained, exclude intestinal obstruction, especially intussusception, malrotation and a strangulated inguinal hernia. Assess for dehydration and shock.
Red Flag’ clinical features in the vomiting child:
Bile-stained vomit
- Intestinal obstruction
Haematemesis
- Oesophagitis, peptic ulceration, oral/nasal bleeding
Projectile vomiting, in first few weeks of life
- Pyloric stenosis
Vomiting at the end of paroxysmal coughing
- W hooping cough (pertussis)
Abdominal tenderness/abdominal pain on movement
- Surgical abdomen
Abdominal distension
- Intestinal obstruction, including strangulated inguinal hernia
Hepatosplenomegaly
- Chronic liver disease
Blood in the stool
Intussusception, gastroenteritis – salmonella or campylobacter
Severe dehydration, shock
- Severe gastroenteritis, systemic infection (urinary tract infection, meningitis), diabetic ketoacidosis
Bulging fontanelle or seizures
- Raised intracranial pressure
Failure to thrive
- Gasto-oesophageal reflux
Causes of vomiting
Pyloric stenosis
Management
- The initial priority is to correct any fluid and electrolyte disturbance with intravenous fluids (0.45% saline and 5% dextrose with potassium supplements).
- Once hydration and acid–base and electrolytes are normal, definitive treatment by pyloromyotomy can be performed.
- This involves division of the hypertrophied muscle down to, but not including, the mucosa .
- The operation can be performed either as an open procedure via a periumbilical incision or laparoscopically.
- Postoperatively, the child can usually be fed within 6 h and discharged within 2 days of surgery.
Clinical features are:
- Vomiting, which increases in frequency and forcefulness over time, ultimately becoming projectile
- Hunger after vomiting until dehydration leads to loss of interest in feeding
- Weight loss if presentation is delayed.
- A hypochloraemic metabolic alkalosis with a low plasma sodium and potassium occurs as a result of vomiting stomach contents.
Diagnosis:
- Unless immediate fluid resuscitation is required, a test feed is performed. The baby is given a milk feed, which will calm the hungry infant, allowing examination.
- Gastric peristalsis may be seen as a wave moving from left to right across the abdomen .
- The pyloric mass, which feels like an olive, is usually palpable in the right upper quadrant . If the stomach is overdistended with air, it will need to be emptied by a nasogastric tube to allow palpation.
- Ultrasound examination is helpful if the diagnosis is in doubt
Causes of vomiting
Gastro-oesophageal reflux
Complications of gastro-oesophageal reflux
Failure to thrive from severe vomiting
Oesophagitis – haematemesis, discomfort on feeding or heartburn, iron deficiency anaemia
Recurrent pulmonary aspiration – recurrent pneumonia, cough or wheeze, apnoea in preterm infants
Dystonic neck posturing (Sandifer syndrome)
Apparent life-threatening events (ALTE)
Investigation:
- 24-hour oesophageal pH monitoring to quantify the degree of acid reflux (see Case History 13.1).
- 24-hour impedance monitoring. Available in some centres. Weakly acidic or non-acid reflux, which may cause disease, is also measured.
- Endoscopy with oesophageal biopsies to identify oesophagitis and exclude other causes of vomiting.
Acute abdominal pain
- Lower lobe pneumonia may cause pain referred to the abdomen
- Primary peritonitis is seen in patients with ascites from nephrotic syndrome or liver disease
- Diabetic ketoacidosis may cause severe abdominal pain
- Urinary tract infection, including acute pyelonephritis, is a relatively uncommon cause of acute abdominal pain, but must not be missed. It is important to test a urine sample, in order to identify not only diabetes mellitus but also conditions affecting the liver and urinary tract.
Acute abdominal pain
Acute appendicitis
Commonest cause of abdominal pain in childhood requiring surgical intervention. Although it may occur at any age, it is very uncommon in children <3 years old. The clinical features of acute uncomplicated appendicitis are:
Symptoms
- Anorexia
- Vomiting (usually only a few times)
- Abdominal pain, initially central and colicky (appendicular midgut colic), but then localising to the right iliac fossa (from localised peritoneal inflammation)
Signs:
- Flushed face with oral fetor
- Low-grade fever 37.2–38°C
- Abdominal pain aggravated by movement, e.g. on walking, coughing, jumping, bumps on the road during a car journey
- Persistent tenderness with guarding in the right iliac fossa (McBurney’s point)
Acute abdominal pain
Non-specific abdominal pain and mesenteric adenitis
Acute abdominal pain in older children and adolescents
Exclude medical causes, in particular lower lobe pneumonia, diabetic ketoacidosis, hepatitis, pyelonephritis
Check for strangulated inguinal hernia or torsion of the testis in boys
On palpating the abdomen in children with acute appendicitis, guarding and rebound tenderness are often absent or unimpressive, but pain from peritoneal inflammation may be demonstrated on coughing, walking or jumping
To distinguish between acute appendicitis and non-specific abdominal pain may require close monitoring and repeated evaluation in hospital.
- Non-specific abdominal pain (NSAP) is abdominal pain which resolves in 24–48 h.
- The pain is less severe than in appendicitis, and tenderness in the right iliac fossa is variable. It is often accompanied by an upper respiratory tract infection with cervical lymphadenopathy.
- In some of these children, the abdominal signs do not resolve and an appendicectomy is performed.
- The diagnosis of mesenteric adenitis can only be made definitively in those children in whom large mesenteric nodes are seen at laparotomy or laparoscopy and whose appendix is normal.
Summary
Intussusception
Summary
Intussusception:
- Usually occurs between 3 months and 2 years of age
- Clinical features are paroxysmal, colicky pain with pallor, abdominal mass, redcurrant jelly stool
- Shock is an important complication and requires urgent treatment
- Reduction is attempted by rectal air insufflation unless peritonitis is present
- Surgery is required if reduction with air is unsuccessful or for peritonitis.
Presentation is typically with:
- Paroxysmal, severe colicky pain and pallor, the child becomes pale, especially around the mouth, and draws up his legs. He initially recovers between painful episodes, but subsequently becomes increasingly lethargic
- refuse feeds, may vomit, which may become bile-stained depending on the site of the intussusception
- sausage-shaped mass – often palpable in the abdomen
- characteristic redcurrant jelly stool comprising blood-stained mucus
- Abdominal distension and shock
Meckel diverticulum
Summary
Meckel diverticulum:
- Occurs in 2% of individuals.
- Generally asymptomatic, but may present with bleeding (which may be life-threatening), intussusception, volvulus or diverticulitis.
- Treatment is by surgical resection.
- 2% of individuals have an ileal remnant of the vitello-intestinal duct, a Meckel diverticulum, which contains ectopic gastric mucosa or pancreatic tissue
- present with severe rectal bleeding, which is classically neither bright red nor true melaena
- Other forms of presentation include intussusception, volvulus around a band, or diverticulitis which mimics appendicitis
- Treatment is by surgical resection.
Malrotation
Malrotation
- Uncommon but important to diagnose
- Usually presents in the first 1–3 days of life with intestinal obstruction from Ladd bands obstructing the duodenum or volvulus
- May present at any age with volvulus causing obstruction and ischaemic bowel
- Clinical features are bilious vomiting, abdominal pain and tenderness from peritonitis or ischaemic bowel
- An urgent upper gastrointestinal contrast study is indicated if there is bilious vomiting
- Treatment is urgent surgical correction.
Recurrent abdominal pain
Recurrent abdominal pain
- often defined as pain sufficient to interrupt normal activities and lasts for at least 3 months. It occurs in about 10% of school-age children
- recognised that many will have one of three distinct symptom constellations:resulting from functional abnormalities of
gut motility or enteral neurons –
- irritable bowel syndrome (most common),
- abdominal migraine or
- functional dyspepsia
Recurrent abdominal pain
Abdominal migraine
- Abdominal migraine is often associated with abdominal pain in addition to headaches, and in some children the abdominal pain predominates.
- The attacks of abdominal pain are midline associated with vomiting and facial pallor. There is usually a personal or family history of migraine.
Recurrent abdominal pain
Irritable bowel syndrome
- associated with altered gastrointestinal motility and an abnormal sensation of intra-abdominal events
- Studies of pressure changes within the small intestine of children with irritable bowel syndrome suggest that abnormally forceful contractions occur
- often a positive family history and a characteristic set of symptoms, although not all patients experience every symptom:
- Abdominal pain, often worse before or relieved by defecation
- Explosive, loose or mucousy stools
- Bloating
- Feeling of incomplete defecation
- Constipation (often alternating with normal or loose stools).
Recurrent abdominal pain
Peptic ulceration, gastritis and functional dyspepsia
- identification of the Gram-negative organism Helicobacter pylori (H. pylori) in association with antral gastritis have focused attention on it as a potential cause of abdominal pain in children
- H. pylori causes a nodular antral gastritis which may be associated with abdominal pain and nausea
- organism produces urease, which forms the basis for a laboratory test on biopsies, and the 13C breath test following the administration of 13C-labelled urea by mouth
- treated with proton pump inhibitors, e.g. omeprazole, and if investigations suggest they have an H. pylori infection, eradication therapy should be given (amoxicillin and metronidazole or clarithromycin)
Gastroenteritis
Conditions which can mimic gastroenteritis
Systemic infection Septicaemia, meningitis
Local infections Respiratory tract infection, otitis media, hepatitis A, urinary tract infection
Surgical disorders Pyloric stenosis, intussusception, acute appendicitis, necrotising enterocolitis, Hirschsprung disease
Metabolic disorder Diabetic ketoacidosis
Renal disorder Haemolytic uraemic syndrome
Other Coeliac disease, cow’s milk protein intolerance, adrenal insufficiency
- most frequent cause of gastroenteritis in developed countries is rotavirus infection
- accounts for up to 60% of cases in children <2 years of age, particularly during the winter and early spring
- effective vaccine against rotavirus is now available, but has not been adopted into the national immunisation programme
- In gastroenteritis there is a sudden change to loose or watery stools often accompanied by vomiting
Gastroenteritis
Assessment
The following children are at increased risk of dehydration:
- Infants, particularly those under 6 months of age or those born with low birthweight.
- If they have passed ≥6 diarrhoeal stools in the previous 24 h
- If they have vomited three or more times in the previous 24 h
- If they have been unable to tolerate (or not been offered) extra fluids
- If they have malnutrition.
history and examination are used to assess the degree of dehydration as:
- No clinically detectable dehydration (usually <5% loss of body weight)
- Clinical dehydration (usually 5–10%)
- Shock (usually >10%). Shock must be identified without delay
Gastroenteritis
Hypernatraemic dehydration
- Infrequently, water loss exceeds the relative sodium loss and plasma sodium concentration increases (hypernatraemic dehydration)
- usually results from high insensible water losses (high fever or hot, dry environment) or from profuse, low-sodium diarrhoea
Signs of extracellular fluid depletion are therefore less per unit of fluid loss, and depression of the fontanelle, reduced tissue elasticity and sunken eyes are less obvious. This makes this form of dehydration more difficult to recognise clinically, particularly in an obese infant. It is a particularly dangerous form of dehydration as water is drawn out of the brain and cerebral shrinkage within a rigid skull may lead to jittery movements, increased muscle tone with hyperreflexia, altered consciousness, seizures and multiple, small cerebral haemorrhages. Transient hyperglycaemia occurs in some patients with hypernatraemic dehydration; it is self-correcting and does not require insulin
Fluid management of deyhdration
Management of hyponatraemic dehydration
