Paediatric Gastroenterology Flashcards
4 presentations of vomiting
Vomiting with retching
Projectile vomiting
Effortless vomiting
Bilious vomiting
Symptoms of vomiting pre-ejection phase
Pallor
Tachycardia
Nausea
Stimuli of vomiting centres
Enteric pathogens Intestinal inflammation Metabolic derangement Infection Head injury Visual stimuli Middle ear stimuli
Differentials for case 6 week old baby 3 week history of vomiting after every feed Bottle fed 6 ounces hourly Vomit - large volume, mikly/curdy, projectile Irritable, crying Not gaining any weight Dehydrated
Gastrooesophageal reflux
Overfeeding
Pyloric stenosis
Signs of pyloric stenosis with further examination/investigation
Test feed
Palpation of olive tumour
Visible gastric peristalsis
Investigations for pyloric stenosis
Blood gas
Ultrasound
Management of pyloric stenosis
Fluid resuscitation
Ramstedts pyloromyotomy
Which group of patients does pyloric stenosis commonly present in?
Babies 4-12 weeks
More common in boys
Symptoms of pyloric stenosis
Projectile non-bilious vomiting, particularly 30 minutes after feed
Dehydration
Weight loss
Shock
Electrolyte disturbance characteristic of pyloric stenosis
Hypochloraema
Hypokalemia
Metabolic alkalosis
Why does bilious vomiting occur?
Intestinal obstruction until proven otherwise
Cases of bilious vomiting
Malrotation Intussusception Atresia Ileus Crohns with strictures
Investigations of bilious vomiting
Abdominal x-ray
Contrast meal
Laparotomy
Most common cause of effortless vomiting
Gastrooesophageal reflux
Prognosis of effortless vomiting due to GOR
Usually self-limiting
Exceptions to self-limiting effortless vomiting/reflux
Cerebral palsy
Progressive neurological problems
Oesophageal atresia +/- TOF operated
Generalised GI motility
Presenting symptoms of gastrooesophageal reflux
Vomiting
Haematemesis
Feeding problems
Failure to thrive
Apnoea
Cough
Wheeze
Chest infections
Sandrifer’s syndrome
What is sandrifer’s syndrome?
Neurological disorder - movement associated Nodding Rotation of head Spastic torticollis Dystonic movement
Movement could be to ease discomfort
Assessment of gastrooesophageal reflux
History Examination Radiology - video fluoroscopy / barium swallow pH study Oesophageal impedance monitor Endoscopy
4 elements of treatment for Gastrooesophageal reflux
Feeding Advice
Nutritional support
Medical
Surgical
Management of feeding in gastrooesophageal reflux
Using thickeners for liquids
Looking at food textures and amounts
Behavioural programme - oral stimulation, remove aversive stimuli
Feeding position
Nutritional management of gastrooesophageal reflux
Calorie supplements
Exclusion diet
NG tube
Gastrotomy
Medical management of gastrooesophageal reflux
Food thickeners - gaviscon
Prokinetic drugs
Acid suppressing drugs - PPIs, H2R blockers
Indications for surgery in gastrooesophageal reflux
Failure to thrive
Aspiration
Oesophagitis
Surgical interventions for gastrooesophageal reflux
Nissens fundoplication
Complications of nissen fundoplication
Post op in cerebral palsy - bloating, dumping |(sweating and diarrhoea) and retching
May unmask other GI motility issues
Definition of chronic diarrhoea
Greater than 4 stools per day for weeks
Causes of diarrhoea
Motility disturbance - toddlers diarrhoea, IBS
Active secretion - acute infective, inflammatory bowel disease
Malabsorption of nutrients - Coeliac, food allergy, cystic fibrosis
4 types of diarrhoea
Osmotic
Secretory
Motility
Inflammatory
Causes of motility diarrhoea
Toddlers
IBS
Congenital hyperthyroidism
Chronic intestinal pseudo obstruction
Cause of secretory diarrhoea
Enterotoxigenic e coli
Vibrio cholerae
Active chloride secretion by CFTR
Clinical approach to assessing child with diarrhoea
History - Age of onset = Abrupt/gradual onset - Family history -Nocturnal defecation
Weight of child and growth
Faeces analysis - stool culture
What does nocturnal defecation in a child presenting with diarrhoea indicate?
Organic cause
Causes of fat malabsorption
Pancreatic disease
Hepatobiliary disease - chronic liver disease, cholestasis
Signs and symptoms of coeliac disease
Abdominal bloatedness Diarrhoea Failure to thrive Short stature Constipation Tiredness Dermatitis herpatiformis
Screening for coeliac disease
Serology
Duodenal biopsy
Genetic testing
Which serological tests are carried out for coeliac disease?
Anti-tissue transglutaminase
Anti endomysial
Antigliadin
What deficiency can result in false negatives in serological testing for coeliac disease?
IgA
Which genes are tested for coeliac disease?
HLA DQ2
DQ 8 Positive
How might a child be diagnosed with coeliac without performing a duodenal biopsy>
Symptomatic
Anti TTG > times 10 of normal upper limit
Positive anti endomysial antibodies
HLA DQ2 DQ8 positive
Treatment for coeliac disease
Gluten free diet for life
( cannot exclude gluten prior to diagnosis)
Can rechallenge and rebiopsy in children who present under 2 years of age
Leaving coeliac disease untreated can result in what condition
Greater risk of rare small bowel lymphoma
What percentage of infants experience regurgitation?
40%`
When is regurgitation and gastrooesophageal reflux most likely to present?
Around 2 weeks
Define regurgitation
Passing of stomach contents beyond the oesophagus
Risk factors for GOR/GORD in infantsq
Prematurity
Parental history of heartburn or acid regurgitation
Obesity
Hiatus hernia
History of (repaired) congenital diaphragmatic hernia
History of (repaired) congenial oesophageal atresia
Neurodisability (eg. cerebral palsy)
Example of a full feeding history
Check position, attachment, technique, duration, frequency and type of milk.
Calculate the volume of milk being given as babies can be over-fed and therefore have gastric over-distension.
Ask about frequency and estimated volume of vomits
Find out the relationship of symptoms to feeds.
Symptoms to enquire about related to episodes of GORD
Distressed behaviour (eg. excessive crying, unusual neck postures, back-arching)
Unexplained feeding difficulties (refusing feeds, gagging, choking)
Hoarseness and/or chronic cough in children
A single episode of pneumonia
Faltering growth
If child is able to they may report retrosternal or epigastric pain
Other differentials for GORD
Pyloric stenosis: Frequent, forceful (projectile) vomiting in <2 month olds
Intestinal obstruction: bile-stained (green or yellow-green) vomit, such as malrotation volvulus
Any acute surgical abdominal issue: abdominal distension, tenderness, or palpable mass
Upper gastrointestinal bleed: haematemesis (beware swallowed blood from cracked nipple if breastfeeding or patient with epistaxis)
Sepsis: altered responsiveness, severe prolonged vomiting, petechial rash, bulging fontanelle if central nervous system involvement
Raised intracranial pressure: rapidly increasing head circumference (>1cm per week), persistent headache and vomiting following periods of recumbence (eg. in morning)
Blood in stool: consider bacterial gastroenteritis, cow’s milk protein allergy.
Chronic diarrhoea, especially if atopic: consider cow’s milk protein allergy.
Urinary tract infection especially if associated with lower urinary tract symptoms
If onset is >6 months of age or symptoms persist beyond 1 year then reflux is unlikely
Conditions related with coeliac disease
Type 1 diabetes
Down syndrome
Turner syndrome
Other autoimmune diseases, such as thyroid disease, rheumatoid arthritis & Addison’s disease.
Histological changes in biopsy for coeliac
Crypt hyperplasia
Villous atrophy
Differential diagnosis for coeliac disease
Tropical sprue Cystic fibrosis Inflammatory bowel disease Post – gastroenteritis Autoimmune enteropathy Eosinophilic enteritis
Classification of duodenal biopsy for coeliac disease
Stage Definition
0 Normal
1 Increased intraepithelial lymphocytes
2 Increased inflammatory cells and crypt hyperplasia
3 All of the above plus mild to complete villous atrophy – specific to coeliac disease
Complications of coeliac disease
anaemia
osteopenia/ osteoporosis
refractory coeliac disease( symptoms persist despite diet, my need treatment with steroids)
malignancy
fertility problems/ adverse events during pregnancy
depression/ anxiety (11, 12)
