Paediatric upper and lower GI disorders

Question 1

What would constipation be defined as?

Answer 1

Hard to say since there is such variation in stool frequency etc

General rule: if the stool is hard and painful to pass then it’s constipation

Question 2

What are some of the signs and symptoms associated with constipation?

Answer 2

Poor appetite 
Irritability 
Lack of energy 
Abdominal pain or distension
Withholding or straining 

Diarrhoea (liquid overflow)

Question 3

What are some of the causes of children becoming constipated?

Answer 3

Social

• Poor diet (insufficient fluids / excessive milk)
• Potty training / school toilet

Physical
- Illness / medications

Psychological

Organic (hypothyroidism)

Question 4

What is the “vicious cycle” when it comes to childrens constipation?

Answer 4

The kid will evacuate their bowels and this may be painful

They will then resist going to the toilet the next time round and the stool will become harder and bigger, making it more painful to evacuate

After the next bit of pain when going to the toilet the childs instinct to not go becomes even stronger

Question 5

What differences to diets would you suggest in a child suffering from constipation?

Answer 5

Increased fibre
Increased fruit
Increased vegetables
Increased fluids

Decreased milk

Question 6

What are some options for pharmaceutical management of constipation?

Answer 6

Osmotic laxatives (lactulose)

Stimulant laxatives (senna / picosulphate)

Isotonic laxatives (movicol / laxido)

Question 7

What is one of the main complications that can occur if a child is experiencing severe, or recurrent constipation?

Answer 7

Megarectum

• Can lead to urinary retention and UTI’s
• Can lead to faecal incontinence due to inability to keep internal sphincter closed

Question 8

What is one of the most important things to remember when prescribing laxatives to a kid?

Answer 8

Want to do it for long enough that they get their confidence back, want them to believe that it won’t be painful when they empty their bowels

Question 9

What are three of the main symptoms of ulcerative colitis?

Answer 9

Diarrhoea *** (esp. nocturnal & bloody)

Rectal bleeding

Abdominal pain

Question 10

What can be some important signs of Crohn’s in children that aren’t always seen in adults?

Answer 10

Growth failure

Weight loss

Question 11

When looking at a childs growth and development charts, what is important to consider?

Answer 11

That longitudinal results are often more useful than one off results

Lot of variation so one off measurements might make a patient look very abnormal, but more important is their rate of growth etc. bc that shows they are developing

Question 12

What is erythema nodosum? Crohns or UC?

Answer 12

Red patches on the fatty layer of the skin

More common in Crohn’s but can be both

Question 13

What are some other important extraintestinal signs of IBD?

Answer 13

Angular cheilitis

Aphthous ulceration

Perianal signs (fissures)

Question 14

What are some laboratory investigations that can be done with suspected IBD?

Answer 14

• FBC & ESR (anaemia, thrombocytosis, raised ESR)
• Biochemistry (raised stool calprotectin**, raised CRP, low albumin)
• Microbiology (rule out infections)

Question 15

Which IBD are children more prone to getting? Are boys or girls more likely to be affected?

Answer 15

Crohn’s

Boys (slight)

Question 16

What sort of colitis is a child with UC likely to display? How is this different from adults?

Answer 16

Pancolitis

Adults: More commonly proctitis / L sided colitis

Children have a much more severe phenotype

Question 17

What parts of the GI tube are likely to be inflamed in children? In adults?

Answer 17

Children likely to have panenteric inflammation (entire tube) including upper GI.
Children also commonly present with ileocolonic inflammation

Adults are usually ileocolonic or isolated ileal

Children have the more severe disease phenotype

Question 18

What non-lab investigations are done on children with suspected or diagnosed IBD?

Answer 18

Radiological:

• MRI (esp. Crohn’s)
• Barium meal and follow through

Endoscopy:

• Colonoscopy and upper GI endoscopy
• Mucosal biopsy
• Capsule enteroscopy
• Enteroscopy

Question 19

What is the cardinal histological signs of Crohn’s disease?

Answer 19

Granuloma

Question 20

Why does treatment of paediatric IBD need to be a lot more strict and intense than adult IBD?

Answer 20

A flare up in an adult produces some uncomfortable symptoms and all but isn’t the end of the world

In children it can be enough to give them growth abnormalities and developmental obstacles, so is more severe

Kids just also tend to have more severe disease

Question 21

What are the classes of pharmaceuticals given to children with IBD?

Answer 21

Anti-inflammatory meds (steroids etc.)

Immunosuppressants

Biologics (eg. infliximab)

Question 22

What is one nutritional method of inducing remission in children (and adults) with Crohn’s disease?

Answer 22

Elemental feeding

liquid nutrients

Question 23

What is the stepwise management plan for Crohn’s?

Answer 23

1. Nutritional support and steroids (prednisolone oral)
2. Immune therapies (azathioprine, 6MP, methotrexate)
3. Biologics (infliximab / adalibumab)
4. Surgery

Question 24

Should surgery ever be done before biologics in Crohn’s?

Answer 24

If the child has one very small isolated area of inflammaiton that is affecting their growth it can be better to just resect that area instead of stepping up to biologics if the rest of the GI tract is doing alright