Paediatric GI - GORD, Intussusception, Hirschsprung, Gastroenteritis and Pyloric Stenosis Flashcards
What happens in intussusception?
One segment of bowel telescope and invaginate into adjacent distal bowel
What part of the bowel is most likely to intussuscept?
Enlarged peyers patch in the ileum
What does invagination of the bowel lead to?
Engorgement of the bowel which eventually goes gangrenous
What classical triad of symptoms does intussusception normally present with?
Colicky abdominal pain
Bilious Vomiting
Sausage shaped abdominal mass
What other symptoms does intussusception present with?
Pallor Distress Drawing up legs Rectal bleeding - redcurrant jelly stool Peritonitis and shock
When is intussusception most common?
6-18 months
Post viral gastroenteritis - peyers patches enlarged
What imaging would you choose to visualise intussusception and what would you expect to see?
USS
Target sign
If you suspect intussusception, what should you do?
Immediate diagnostic enema
How is intussusception managed?
Supportive care - large volume of fluids, antibiotics, analgesia, NG tube
Pneumatic resolution - rectal insufflation of air
Operative reduction
What is the pathophysiology of Hirschprung’s Disease?
Failure of parasympathetic ganglion cells to move to the myenteric plexus
So no coordinated peristalsis
So functional obstruction due to no relaxing at transition zone
How do infants with Hirschprung’s present?
Present in first few days of life:
Failure to pass meconium >48h
Lower intestinal obstruction
Abdominal distention
Bilious vomit
What is a severe life-threatening complication of Hirschprung’s? How would it present?
Enterocolitis (C.Diff)
Pain, distention, watery, bloody diarrhoea, sepsis
How can older children present with Hirschprung’s?
Chronic severe constipation from birth
Abdominal distention
Absence of faeces in narrow rectum
How is Hirschprung’s diagnosed?
Barium enema to demonstrate change in diameter
Confirmation by suction biopsy showing absence of ganglion cells
How is Hirschprung’s managed?
Surgical removal of aganglionic bowel
Pull through anastomosis of normal bowel with anus
What is Hirschprung’s associated with?
Down’s syndrome
What is GORD?
Effortless reflux of contents back into the oesophagus. It is repeated and severe enough to cause harm
What makes GORD common in babies?
Liquid diet
Horizontal position
Low resting lower oesophageal sphincter pressure
Slow gastric emptying
What puts children at extra risk of having GORD?
Prematurity Parental history of GORD Obesity Hernia (inc history of hernia) Neurodisability
How does GORD present in children?
Regurgitation Irritability Feeding difficulty Failure to thrive - calorie deficiency Sandifers syndrome Resp symptoms
What is sandifers syndrome?
Extension and lateral turning of the head and dystonic posture
What do you ask about in a feeding history?
Position Attachment Technique Duration Frequency Type and volume of milk Vomits Relationship of symptoms to feed
What do you assess on physical examination of a child with GORD?
Hydration status
Signs of malnutrition
Growth charts
How can GORD be diagnosed?
Mostly clinical diagnosis
Can do:
24hr oesophageal pH studies
Barium studies
Endoscopy
How is GORD managed conservatively?
Nurse infants head at 30 degrees
Thickened feeds, small frequent meals, no food before sleep, avoid acidic fatty foods
Reassure it will resolve
What medical and surgical management options are there for GORD?
Ranitidine or Omeprazone
Prokinetic drugs - domperidone (speed up gastric emptying)
Nissen’s fundoplication
What complications can GORD lead to?
Oesophageal stricture
Barrett’s oesophagus
Failure to thrive
Anaemia
What can cause gastroenteritis?
Virus - ROTAVIRUS, norovirus, adenovirus
Bacterial - Campylobacter, Salmonella, Shigella, E. COli
How is gastroenteritis typically characterised?
Sudden onset diarrhoea with or without vomiting
How does gastroenteritis present?
Watery diarrhoea Vomiting Cramping abdo pain Fever Dehydration Electrolyte disturbance
What additional features would make you think the gastroenteritis is bacterial?
Dysentery
Malaise
Tenesmus
How is gastroenteritis normally transmitted?
Faecal-oral transmission
How long do vomiting and diarrhoea each normally last in gastroenteritis?
Vomiting - 1-2 days
Diarrhoea - 5-7 days
Which children are at greatest risk of dehydration?
<6 months old
Pass >5 stools in last 24 hrs
Vomit >2x in last 24 hrs
Children stopped breastfeed while ill
When would you admit a child with gastroenteritis?
Signs systemically unwell
>10% dehydrated
Unable to tolerate oral fluids
No improvement in 48hours
What investigations may you consider for gastroenteritis?
Stool and blood culture
Plasma U&E - consider hypernatraemic dehydration
How do you treat gastroenteritis?
Supportive rehydration
Rotavirus vaccine
Hygiene advice - no school for 48 hours
What are the maintenance fluid requirements for a child?
0-10kg - 100ml/kg/day
10-20kg - 50ml/kg/day
20+ kg - 20ml/kg/day
How do you rehydrate a child who is normonatraemically dehydrated?
Maintenance fluid + Rehydration
Done over 24hours
Rehydration = body mass x % dehydrated x 10
How do you rehydrate a child who is hypernatraemically dehydrated?
Maintenance fluid x2 + rehydration
Done over 48 hours ( x2 maintenance)
Rehydration = body mass x % dehydrated x 10
What is the role of antibiotics in gastroenteritis?
Not commonly needed as don’t change symptoms
Given if:
Risk of disseminated disease
Systemically unwell
<6months old
C.Diff
What are possible complications of gastroenteritis?
Haemolytic uraemic syndrome
Toxic megacolon
Acquired/secondary lactose intolerance
What causes pyloric stenosis?
Hypertrophy of the smooth circular muscle of the pylorus –> narrowed pyloric canal
What is the incidence of pyloric stenosis?
1-2 per 1000 live births
What are the risk factors for pyloric stenosis?
Male 4:1
White
Family history
How does pyloric stenosis present?
2-8 weeks old
Projectile, non-bilious vomit after every feed
Hungry
Constipation
Dehydration
What can you see on examination of a child with pyloric stenosis?
Visible peristalsis
Palpable olive sized pyloric mass - esp. during feed
What tests are done to diagnose pyloric stenosis?
Test feed
USS
Bloods - hypochloraemic, hypokalaemic metabolic alkalosis
How is pyloric stenosis managed?
Correct fluid and electrolyte abnormality
Empty stomach - NG tube
Ramstedt’s Pyloromyotomy - thickened pyloric muscle split
When is surgical correction of pyloric stenosis done?
After fluid and electrolyte abnormalities have been corrected
