Paediatric Gastroenterology Flashcards
indications for enteral nutrition: inadequate oral intake
disorders of suckling and swallowing prematurity neurological impairment congenital abnormalities of oesophagus oral/head neck tumours trauma and extensive burns severe gastroesophageal reflux mechanical ventilation/cardiorespiratory disease food aversion anorexia
indications for enteral nutrition: disorders of digestion and absorption
CF short bowel syndrome IBD malabsorption due to food allergy protracted diarrhoea of infancy chronic liver disease intestinal fistula disorders of gastrointestinal motility e.g. chronic pseudo-obstruction, gastroparaesis growth failure or chronic malnutrition metabolic disease hypermetabolic status
factors to consider for percutaneous endoscopic gastrostomy
psychosocial factors ethics and prognosis quality of life information and consent clinical status
complications of enteral tubes
infection of stoma site
over granulation of stoma site
buried bumper (Freka PEG)
tube dislodgement
risks of enteral tubes
wrong port used
blockage of tube
tube falls out
types of vomiting
- Vomiting with retching
- Projectile vomiting
- Bilious vomiting
- Effortless vomiting
phases of vomiting with retching
• Pre-ejection phase o Pallor o Nausea o Tachycardia • Ejection Phase o Retch o Vomit • Post-ejection Phase o Weakness o Shivering o Lethargy
stimulation of vomiting centre
- Enteric pathogens
- Intestinal inflammation
- Metabolic derangement
- Infection
- Head injury
- Visual stimuli
- Middle ear stimuli
who gets pyloric stenosis?
babies 4-12 weeks
boys>girls
pyloric stenosis features
projectile non-bilious vomiting
weight loss
dehydration +/- shock
characteristic electrolyte disturbance in pyloric stenosis
o Metabolic alkalosis (↑pH) o Hypochloraemia (↓Cl) o Hypokalaemia (↓K)
gastroesophageal reflux in children
- Movement of gastric contents into the oesophagus
- Effortless vomiting
- Very common problem in infants
- Usually self-limiting and resolves spontaneously
presenting symptoms of malabsorption in children
• Gastrointestinal o Vomiting o Haematemesis • Nutritional o Feeding problems o Failure to thrive • Respiratory o Apnoea o Cough o Wheeze o Chest infections • Neurological o Sandifer’s syndrome
what is Sandifer’s syndrome?
Sandifer’s syndrome is the association of gastro-oesophageal reflux disease with spastic torticollis and dystonic body movements. Nodding and rotation of the head, neck extension, gurgling sounds, writhing movements of the limbs, and severe hypotonia have been reported. It is hypothesised that such positionings provide relief from discomfort caused by acid reflux. A causal relation between gastro-oesophageal reflux disease and the neurological manifestations of Sandifer’s syndrome is supported by the resolution of the manifestations on successful treatment of gastro-oesophageal reflux disease. The clinical manifestations almost invariably arouse the suspicion of neurological disease and lead to unnecessary investigative procedures.
medical assessment of vomiting and malabsorption
• History & examination often sufficient • Radiological investigations o Video fluoroscopy(only if swallowing problems) o Barium swallow § Dysmotility § Reflux § Gastric emptying § Strictures • pH study • Oesophageal impedance monitoring • Endoscopy
treatment of vomiting and malabsorption in children
feeding advice
nutritional support
medical treatment
surgery
feeding advice in vomiting and malabsorption in children
o Feed thickeners (Carobel) o Appropriateness of foods § Texture § Amount o Behavioural programme § Oral stimulation § Removal of aversive stimuli o Feeding position
nutritional support in vomiting and malabsorption in children
o Calorie supplements
o Exclusion diet (milk free)
o Nasogastric tube
o Gastrostomy
medical treatment n vomiting and malabsorption in children
o Feed thickener § Gaviscon, Thick and Easy o Prokinetic drugs o Acid suppressing drugs § H2 receptor blockers § PPIs
surgery n vomiting and malabsorption in children
o Indications § Failure of medical treatment § Persistent • Failure to thrive • Aspiration • Oesophagitis o Vomiting without complications is not an indication
describe nissen fundoplication
Children with cerebral palsy are more likely to have complications of bloat, dumping and retching after surgery. Successful surgery may unmask more generalised GI motility problems in the child. The postoperative course may be more complicated in children with cerebral palsy. Dumping relates to early jejunal filling due to rapid gastric emptying and can lead to unpleasant symptoms such as intermittent sweating and diarrhoea following meals.
causes of bilious vomiting in children
- Intestinal atresia (in newborn babies only)
- Malrotation +/- volvulus
- Intussusception
- Ileus
- Crohn’s disease with strictures
bilious vomiting in should is always what until proven otherwise
intestinal obstructions
investigations of bilious vomiting in children
- AXR
- Consider contrast meal
- Surgical opinion re exploratory laparotomy
the small intestine secretory component
• Water for fluidity/enzyme transport/absorption
• Ions e.g. duodenal HCO3
-
• Defence mechanism against pathogens/harmful substances/antigens
o Flushes them out
define chronic diarrhoea in children
presence of 4 or more stools per day for more than 4 weeks
causes of diarrhoea in children
• Motility disturbance o Toddler diarrhoea o Irritable bowel syndrome • Active secretion (Secretory) o Acute infective diarrhoea o Inflammatory bowel disease • Malabsorption of nutrients (osmotic) o Food allergy o Coeliac disease o Cystic fibrosis
type of carbohydrate malabsorption in children
• Primary lactose malabsorption very rare • Secondary lactose malabsorption • Glucose-galactose malabsorption Figure 8 Small Intestine Mucosa • Fructose malabsorption • Disaccharidases deficiency
causes of fat malabsorption in children
• Pancreatic Disease o Diarrhoea due to lack of lipase and resultant steatorrhoea o Classically cystic fibrosis • Hepatobiliary Disease o Chronic liver disease o Cholestasis
features of Shwachman-Diamond syndrome?
pancreatic insufficiency and bone marry dysfunction
neutropenia
secretory diarrhoea mechanism
Secretory diarrhoea is classically associated with toxin production from vibrio cholerae and enterotoxigenic Escherichia coli. In cholera you can lose 24l of fluid per day. Intestinal fluid secretion is predominantly driven by active Cl- secretion via CFTR. This is classically toddler’s diarrhoea. Other causes include IBS, congenital hyperthyroidism, and chronic intestinal pseudo-obstruction.
inflammatory diarrhoea mechanism
Inflammatory diarrhoea is a mixed bad. Malabsorption due to intestinal damage and secretory effect of cytokines. There is accelerated transit time in response to inflammation. Protein exudate across the inflamed epithelium
clinical approach to diarrheoa in children
• History o Age at onset o Abrupt/gradual onset o Family history o Nocturnal defecation suggests organic pathology • Consider growth and weight gain of child • Faeces analysis o Appearance o Stool culture o Determination of secretory vs osmotic