PAEDIATRICS 2 Flashcards
What is the prevalence of asthma in children?
15-20%, 20 deaths a year
What is transient early wheeze in preschool children likely to be?
Episodic viral wheeze, due to tendency of airways to narrow and inflame with viruses
What is persistent wheeze likely to be?
IgE response to allergens
Recurrent wheeze associated with evidence of allergy is atopic asthma
What is the pathophysiology of asthma?
Environmental triggers/allergens lead to bronchial inflammation (oedema, mucous) and hyperresponsiveness, leading to airway narrowing an symptoms of cough/wheeze/SoB/tightness
What are the causes of asthma?
Genetic predisposition (family history) Atopy
Symptoms of asthma? (7)
Wheeze Symptoms worse at night and in early morning Cough Shortness of breath Triggered by allergens/environment Interval symptoms between exacerbations Positive response to therapy
Signs of asthma? (3)
Chest hyperinflation
Eczema
Harrison’s sulcus
How is asthma diagnosed? (5)
Clinically Skin prick test for common allergies CXR to exclude other Peak expiratory flow rate recording - diurnal pattern Check if response to bronchodilator
Management of asthma? (6)
Allergen avoidance
1 - inhaled SHORT acting beta 2 agonist (salbutamol)
2 - ADD an inhaled STEROID (beclometasone, budenoside)
3 - ADD a leukotriene receptor antagonist LTRA (montelukast)
4 - Stop LTRA, refer if under 5, if over 5 add LABA (formeterol)
5 - increase ICS dose
6 - Trial of theophylline
What is the management of acute asthma? (4)
Salbutamol
Oral prednisolone/IV hydrocortisone
Nebulised ipratropium bromide
Oxygen
What is the most common cause of pneumonia in younger and older children?
Viruses in younger children, bacteria in older
Common causative organisms of pneumonia in the newborn?
Group B strep, enterococci
Common causative organisms of pneumonia in infants/young children?
Respiratory syncytial virus
Strep pneumoniae
H.influenzae
Staph aureus is serious
Common causative organisms of pneumonia over 5 years?
M.pneumoniae
Strep pneumoniae
What vaccines are there to prevent pneumonia in children?
Strep pneumoniae
H.influenzae type b
Symptoms of pneumonia? (6)
Fever Difficulty breathing Cough Lethargy Poor feeding Chest/abdo/neck pain
Signs of pneumonia? (4)
Tachypnoea
Nasal flaring
Chest recession
End inspiratory crackles
What is pneumonia usually preceded by?
URTI
Investigations for pneumonia? (4)
CXR
Nasophyaryngeal aspirate to identify cause
FBC
Acute reactants
What may be seen on CXR in pneumonia?
Lobar consolidation
Effusion
Empyema
General management of pneumonia? (5)
Admit if severe Oygen Analgesia IV fluids Abx
What antibotics are used for newborns with pneumonia?
Broad spectrum IV
What antibiotics are used for older children with pneumonia?
Oral amoxicillin
Co-amoxiclav if complicated
Why are children mostly not infectious for TB?
Disease is paucibacillary
How to children commonly catch TB?
From an infected adult in same household, more likely to progress to active disease than in adults
Mycobacterium tuberculosis
Why do 50% of infants and 90% of children show minimal signs of TB?
Inflammation limits progression of disease so it remains latent
What are symptoms of TB? (5)
Fever Anorexia, weight loss Cough CXR changes i.e. hilar lymphadenopathy Older children: fatigue, night sweats, chest pain, bloody sputum
What is the primary Ghon complex and what may it lead to in TB?
Lesion of lung calcification and regional nodes
May lead to bronchial obstruction, lung collapse, pleural effusion
May involve gut, skin
What is post primary TB?
Asymptomatic or symptomatic infections may become dormant and reactivate to post primary TB
May be widely disseminated
What is a complication of post primary TB in infants
Wide dissemination with CNS involvement leading to meningitis
How is TB diagnosed? (5)
Sputum culture Urine sample CSF sample CXR Lymph node excision
Management of suspected TB?
Mantoux test - if positive, treat
Management of TB
Quadruple therapy with rifampicin, isoniazid, pyrazinamide, ethambutol (6 months)
Rifampicin and isoniazid only after 2 months
Longer course if disseminated/meningitis
What is a side effect of isoniazid and how is it prevented? Which TB drug causes red urine? Which can cause visual problems?
Weekly pyridoxine after puberty to prevent peripheral neuropathy
Red urine - rifampicin
Visual - ethambutol
What is prevention of TB?
BCG vaccine at birth for high risk groups
Screen contacts
What is bronchiolitis?
Most common serious respiratory infection of infancy
When are children commonly affected by bronchiolitis?
1-9 months
Winter
What is the most common pathogen for bronchiolitis?
Respiratory syncytial virus in 80%
Others - parainfluenza, rhinovirus
Symptoms of bronchiolitis? (5)
Coryzal features Dry cough Increasing breathlessness Feeding difficulty Recurrent apnoea
Signs of bronchiolitis? (7)
Tachypnoea Sub and intercostal recession Hyperinflation End-inspiratory crackles Wheeze Tachycardia Pallor/cyanosis
Diagnosis of bronchiolitis?
Clinical
Virus on PCR of nasopharyngeal swab
Management of bronchiolitis?
Supportive - humidified oxygen nasal cannulae
IV fluids
Prevention of bronchiolitis?
Palivuzumab for high risk - preterm infants, CF
What is the proper name for croup and what is it?
Laryngotracheobronchitis - mucosal secretions and inflammation affecting the airway, and oedema of the subglottic area which can result in critical narrowing
What is the most common cause of croup?
Parainfluenza viruses
When does croup occur?
From 6 months-6 years
Peak at 2 years
Autumn
Symptoms of croup? (5)
Barking cough Harsh stridor Hoarseness Usually preceded by fever/cold Worse at night
How is croup treated?
Oral dexamethasone (/prednisolone/nebulised budenoside) If severe, nebulised adrenaline and oxygen
What is bacterial tracheitis?
Similar to severe croup but high fever and rapid obstruction
What causes bacterial tracheitis?
Staph aureus
How is bacterial tracheitis treated?
IV antibiotics - penicillin
What is epiglottitis?
Emergency - obstruction risk due to intense epiglottal swelling, associated with septicaemia
DO NOT EXAMINE THROAT
What causes epiglottitis?
H influenzae type B
Symptoms of epiglottitis? (4)
Acute onset High fever Drooling Soft stridor NO COUGH
Treatment of epiglottitis?
Intubated
IV cefuroxime
rifampicin for close contacts
What is cystic fibrosis?
Most common life limiting (average life expectancy 30-40s) autosomal recessive condition in the Caucasian population
What is the cause of cystic fibrosis?
Defective protein of the cystic fibrosis transmembrane conductance regulator (CFTR) on chromosome 7
What are some risk factors that may moderate severity of cystic fibrosis?
Passive smoking
Social deprivation
Modifier genes
What features does the defective protein in cystic fibrosis cause? (6)
Impaired ciliary function
Increased retention of secretions
Chronic bronchial infection - psued aerug
Thick meconium in infants - meconium ileus
Blocked pancreatic ducts leading to enzyme deficiency, malabsorption
Excessive Na and Cl in sweat
What is a common bronchial infection in cystic fibrosis?
Pseudomonas aeruginosa
Screening for cystic fibrosis?
Guthrie test - heel prick
How may cystic fibrosis present in infants? (5)
Recurrent infections Failure to thrive Malabsorption Meconium ileus Prolonged neonatal jaundice
How may cystic fibrosis present in young children? (4)
Bronchiectasis
Nasal polyps
Sinusitis
Rectal prolapse
How may cystic fibrosis present in older children? (5)
Diabetes Cirrhosis Intestinal obstruction Pneumothorax Male infertility
How is cystic fibrosis diagnosed?
Sweat test - elevated chloride level
Genetic testing - abnormalities in CTFR protein
How is cystic fibrosis managed?
MDT approach to suppress lung disease, maintain nutrition and growth
What is treatment of bacterial chest infections in cystic fibrosis? (4)
Physiotherapy to clear secretions
Prophylactic oral flucloxacillin with rescue antibiotics in exacerbations
Daily nebulised pseudomonal antibiotics
Nebulised DNAse/hypertonic saline
What is treatment of severe/end stage respiratory disease in cystic fibrosis?
If severe - regular IV abx, portacath
Bilateral lung transplant
How is pancreatic insufficiency in cystic fibrosis managed?
Pancreatic replacement medication after food
High calorie diet
Fat soluble vitamin supplements
What is the prevalence of significant cardiac malformations in infants?
8/1000, 1/10 stillborn
Give 3 left to right shunts and what the main symptom is
Breathless
Ventricular septal defect (most common)
Patent ductus arteriosus
Atrial septal defect
Give 2 right to left shunts and what the main symptom is
Blue
Tetralogy of Fallot
Transposition of the great arteries
Give an example of a common mixing heart defect and what the symptoms are
Breathless and blue
Atrioventricular septal defect
Give two types of outflow obstruction in a well child and what the symptoms are
Asymptomatic with murmur
Pulmonary stenosis
Aortic stenosis
Give a type of outflow obstruction in the sick neonate and what the symptoms are
Collapse with shock
Coarctation of the aorta
What causes congenital heart defects? (5)
Rubella infection Diabetes SLE Fetal alcohol syndrome Genetics - Down's, Edwards's, Patau, Turner's
How does congenital heart disease present and which is most common? (5)
Picked up antenatally by USS Detection of heart murmur clinically - most common Heart failure Shock Cyanosis
What are the hallmarks of an innocent murmur? (4)
30% of children have an innoSent murmur aSymptomatic patient Soft blowing murmur Systolic only left Sternal edge
When are innocent (flow) murmurs often heard?
When a child has a fever or is anaemic, due to increased cardiac output
What are the two main types of atrial septal defect?
Secundum (80%)
Primum (partial atrioventricular septal defect)
What is secundum ASD?
Defect in the centre of the atrial septum involving the foramen ovale
What is partial AVSD?
Defect of the atrioventricular septum - either between the atrial septum and atrioventricular valves or abnormal atrioventricular valves which leak
What are the symptoms of atrial septal defects? (3)
Commonly asymptomatic
May have recurrent chest infections
Arrhythmias when adults
Signs of atrial septal defects? (3)
Ejection systolic murmur (upper left sternal edge)
Fixed, widely split second heart sound
If partial - apical pansystolic murmur
Investigations for atrial septal defects? (3)
CXR shows cardiomegaly, enlarged pulmonary arteries
ECG - partial right bundle branch block in secundum, abnornal QRS axis in primum
Echocardiography for anatomy
How are atrial septal defects treated if significant?
Secundum - cardiac catheterisation with insertion of occlusion device
Primum - surgical correction at around 3-5 years
What are ventricular septal defects?
Defect anywhere in the ventricular septum, perimembranous (next to tricuspid valve) or muscular
Categorised by size - smaller or larger than the aortic valve
Symptoms of small VSDs?
None
Sign of small VSDs?
Loud pansystolic murmur at lower left sternal edge - loud murmur = smaller defect
Investigations of small VSDs?
CXR and ECG normal
Echocardiogram shows anatomy
Management of small VSDs?
Will close spontaneously
Symptoms of large VSDs? (4)
Heart failure
Breathlessness
Failure to thrive
Recurrent chest infections
Signs of large VSDs? (6)
Tachypnoea Tachycardia Hepatomegaly Active precordium Soft pansystolic murmur or no murmur Apical mid-diastolic murmur
Investigations of large VSDs?
CXR shows cardiomegaly, enlarged pulmonary arteries, pulmonary oedema
ECG biventricular hypertrophy, upright T wave shows pulmonary hypertension
Echocardiogram - anatomy and pulmonary hypertension
Management of large VSDs?
Diuretics
Captopril - ACEi
Extra calories
Surgery at 3-6 months to prevent permanent damage from pulmonary hypertension and high blood flow
What is patent ductus arteriosus?
When ductus arteriosus fails to close within 1 month after due date due to a defect in constrictor mechanism of duct. Connects pulmonary artery to descending aorta so after birth blood flows from aorta to P.A.
Common in prematurity
Symptoms and signs (3) of patent ductus arteriosus?
Continuous murmur below left clavicle
Pulse pressure increased - collapsing/bounding pulse
If large, heart failure and pulmonary hypertension
Normally asymptomatic
Investigations of patent ductus arteriosus?
CXR and ECG normal - if large same appearance as VSDs
Duct identified on echocardiogram
Management of patent ductus arteriosus?
Coil or occlusion closure via cardiac catheterisation at 1 year to avoid risk of bacterial endocarditis, pulmonary vascular disease
What is the most common cause of cyanotic congenital heart disease?
Tetralogy of Fallot
What are the 4 features of tetralogy of fallot?
Large VSD
Overriding aorta
Pulmonary stenosis
Right ventricular hypertrophy
Symptoms of tetralogy of fallot? (4)
Most diagnosed antenatally or within first 2 months after a murmur identified
Severe cyanosis in first few days of life
Hypercyanotic spells later in life
Squatting on exercise later in life
What are hypercyanotic spells? (5)
Rapid increase in cyanosis Irritability/crying Hypoxia Breathlessness Pallor
Signs of tetralogy of fallot?
Clubbing
Harsh ejection systolic murmur at left sternal edge
Investigations for tetralogy of fallot?
CXR shows small heart, with uptilted apex and pulmonary artery ‘bay’
ECG normal at birth, right ventricular hypertrophy when older
Echo for anatomy
Cardiac catheterisation for anatomy
Management of tetralogy of fallot?
Medical
Surgery at 6 months to close VSD
If cyanosed infant - shunt to increase pulmonary blood flow
How are hypercyanotic spells treated? (4)
Sedation, pain relief, fluids
IV propranolol
Bicarbonate for acidosis
Muscle paralysis and artificial ventilation to reduce oxygen demand
How is ductal patency maintained in the first few days of life for duct dependant cyanotic infants?
Prostaglandin infusion
What is transposition of the great arteries?
Aorta is connected to the right ventricle
Pulmonary artery is connected to the left ventricle
Deoxygenated blood is returned to the body - incompatible with life unless there is an associated defect that allows mixing (ASD, VSD, PDA)
Symptoms of transposition of the great arteries?
Cyanosis - usually day 2 after ductal closure as reduces mixing
Less severe if more mixing
Signs of transposition of the great arteries?
Loud, single second heart sound
Variable systolic murmur due to increased pulmonary flow
Investigations of transposition of the great arteries?
CXR - narrow upper mediastinum, ‘egg on side’ appearance of cardiac shadow, increased pulmonary vascular markings
ECG normal
Echo for anatomy and other abnormalities
How is transposition of the great arteries managed?
Improve mixing
Maintain patency of ductus arteriosus - prostaglandin infusion
Balloon atrial septostomy to tear atrial septum and allow mixing
Surgery - arterial switch procedure in neonatal period (first few days of life)
What is eisenmenger syndrome?
If high pulmonary blood flow due to a large left to right shunt or common mixing is not treated, pulmonary arteries become thick walled and resistance to flow increases
At about 10-15 years the shunt reverses and teenager becomes cyanosed
Progressive syndrome, death from heart failure in middle age
How is eisenmenger syndrome treated?
Prevention by treating heart defects early
Transplant
Palliative pulmonary hypertension medication to delay transplantation
What is atrioventricular septal defect?
Common mixing
Seen in Down’s syndrome
Defect in the middle of the heart with a common valve between the atria and ventricles, which leaks
Causes pulmonary hypertension
Features of atrioventricular septal defect? (3)
Presents on fetal USS
Cyanosis at birth or heart failure after 2-3 weeks
No murmur
Management of atrioventricular septal defect
Treat heart failure medically
Surgical repair at 2-3 months
What causes heart failure in neonates?
Obstructed (duct dependant) systemic circulation: Hypoplastic left heart syndrome Critical aortic valve stenosis Severe coarctation of aorta Interruption of aortic arch
What causes heart failure in infants?
High pulmonary blood flow (left to right shunts):
Ventricular septal defect
Atrioventricular septal defect
Large patent ductus arteriosus
What causes heart failure in older children?
Eisenmenger (right heart failure)
Rheumatic heart disease
Cardiomyopathy
Symptoms of heart failure? (4)
Breathlessness
Sweating
Poor feeding
Recurrent chest infection
Signs of heart failure? (7)
Poor weight gain Tachypnoea Tachycardia Heart murmur - gallop rhythm Enlarged heart Hepatomegaly Cool peripheries
Signs of right heart failure?
Ankle and sacral oedema
Ascites
Rare, may be seen with longstanding pulmonary hypertension or rheumatic fever
Complications of heart failure?
Progressive heart failure until 3 months, when symptoms may improve due to rise in pulmonary vascular resistance but this then leads to Eisenmenger’s when the shunt reverses to right to left.
What is sinus arrhythmia?
Normal cyclical change in heart rate with respiration - increasing on inspiration
What is supraventricular tachycardia?
Most common childhood arrhythmia
Rapid heart rate - 250-300 bpm
Premature activation of the atrium via an accessory pathway
How does supraventricular tachycardia present?
Symptoms of heart failure
Poor cardiac output
Pulmonary oedema
Investigation of supraventricular tachycardia?
ECG - narrow complex tachycardia, if severe changes suggestive of myocardial ischaemia (T wave inversion)
Management of supraventricular tachycardia?
Circulatory and respiratory support
Vagal stimulating manoeuvres - carotid sinus massage
IV adenosine breaks re-entry circuit
Electrical cardioversion
What is maintenance therapy of supraventricular tachycardia?
Flecainide or sotalol
What is congenital heart block?
Rare, related to anti-Ro or anti-La antibodies in maernal serum which prevent normal development of the electrical conduction system in the developing heart, with atrophy of the AV node
What are the symptoms of congenital heart block?
May cause death in utero
May cause heart failure neonatally
Most symptom free for a few years
May develop presyncope or syncope
What is management of congenital heart block?
Insertion of endocardial pacemaker
What is coarctation of the aorta?
Arterial duct tissue encircling the aorta just at the point of insertion of the duct
When the duct closes the aorta constricts causing obstruction to left ventricular outflow
How does coarctation of the aorta present if not antenatally?
Collapse when DA closes at 2 days
Severe heart failure and metabolic acidosis
Weak femoral pulses
Management of coarctation of the aorta?
Resus
Prostaglandin infusion
Early surgical repair
What is hypoplastic left heart syndrome?
Undervelopment of the entire left side of the heart, with small ascending aorta
Usually also has coarctation of the aorta
How does hypoplastic left heart syndrome present if not antenatally?
Sickest of all neonates
Duct dependent systemic circulation
No flow through left heart - acidosis and quick cardiovascular collapse
Weak or absent peripheral pulses
Management of hypoplastic left heart syndrome?
Resus, prostaglandin infusion
Early surgery, followed by another at 6 months and another at 3 years
What is rheumatic fever?
Abnormal immune response to a preceding group A beta-haemolytic streptococcus infection
Mainly affects 5-15 year olds, most common cause of heart disease worldwide
How does rheumatic fever present?
Latent interval 2-6 weeks after pharyngeal infection Pancarditis (endo, myo, pericarditis) Polyarthritis Mild fever Malaise
What is chronic rheumatic fever?
Mitral stenosis usually occurs from long term damage and fibrosis of the valve tissue if repeated attacks of rheumatic fever with carditis
Severity of valvular disease related to number of childhood attacks
How is acute rheumatic fever treated? (5)
Anti-inflammatory agents - high dose aspirin
Limit exercise
Corticosteroids if no rapid improvement
Diuretics and ACE inhibitors for heart failure
Anti-streptococcal antibiotics if persistent infection
How is recurrence of rheumatic fever prevented?
Monthly benzathine penicillin injections or oral erythromycin until age of 18-21 years - possibly lifelong
What are risk factors for infective endocarditis?
Congenital heart disease - VSD, coarctation of aorta, patent ductus arteriosus
Prosthetic material inserted at surgery
Symptoms of infective endocarditis?
Fever Malaise Raised ESR Anaemua/haematuria Peripheral stigmata - splinter haemorrhages, clubbig, necrotic skin lesions Cerebral and retinal infarcts
How is endocarditis investigated?
Blood cultures
Echocardiography for vegetations
What is the common causative organism of endocarditis?
Streptococcus viridans (alpha haemolytic)
Treatment of endocarditis?
High dose penicillin and aminoglycoside for 6 weeks
Possible removal of synthetic shunts etc.
Prophylaxis of endocarditis?
Good dental hygiene
What is oesophageal atresia?
Usually associated with tracheo-oesophageal fistula and with polyhdramnios in pregnancy
How is oesophageal atresia diagnosed?
Antenatally
Wide feeding tube passed down and checked with X ray if it reaches the stomach
How does oesophogeal atresia present?
Antenatal USS Salivation Drooling Cough/choking when fed Cyanotic episodes Aspiration of saliva
How is oesophageal atresia treated?
Continuous suction applied to a tube passed to oesophageal pouch
Surgical repair
What is the VACTERL association?
Vertebral Anorectal Tracheo-Esophageal Renal Limb anomalies
How does small bowel obstruction present? (4)
Antenatal USS
Vomiting, possibly bile stained
Delayed/absent stool passing
Abdominal distension
What is bile stained vomit a sign of until proven otherwise?
Bowel obstruction
What may small bowel obstruction be caused by?
Duodenal atresia/stenosis - associated with Down’s syndrome and other congenital malformations
Jejunal/ileal atresia/stenosis - may be atretic bowel
How are small bowel atresia/stenosis treated?
Surgical repair
Correct fluid and electrolyte depletion
What is malrotation with volvulus?
Type of small bowel obstruction
Loop of intestine loops around itself
May lead to infarction of large parts of bowel
How is malrotation with volvulus treated?
Surgically after correction of fluids and electrolytes
What is meconium ileus?
Thick meconium becomes compacted in the lower ileum - almost all affected have cystic fibrosis
How is meconium ileus treated?
Dislodged using gastrografin contrast medium
What is meconium plug?
Plug of thick meconium causes lower intestinal obstruction, passes spontaneously
What causes large bowel obstruction?
Hirschprung’s disease
Rectal atresia
What is rectal atresia?
Absence of anus at the normal site, possible fistula to bladder or vagina
Surgical repair
What is Hirschprung’s disease?
Absence of the ganglion cells from the myenteric and submucosal plexuses in the large bowel results in a narrow, contracted segment
Mostly confined to rectosigmoid but in 10% whole bowel affected
How does Hirschprung’s disease present? (4)
Intestinal obstruction in neonatal period
Failure to pass meconium
Abdominal distension
Bile stained vomit
What is Hirschprung enterocolitis?
Severe bowel inflammation during first few weeks of life caused by Clostridium difficile infection
How does Hirschprung’s disease present in older children? (3)
Chronic constipation
Abdominal distension
Growth failure
How is Hirschprung’s disease diagnosed?
Absence of ganglion cells
Presence of large acetylcholinesterase positive nerve trunks on rectal biopsy
Barium studies to give length of affected segment
How is Hirschprung’s disease treated?
Surgical
Colostomy then anastomosis of normal bowel to anus
What is exomphalos?
(omphalocoele)
Abdominal contents protrude through umbilical ring, covered by a sac of amniotic membrane and peritoneum
Usually associated with other abnormalities
What is gastroschisis?
Bowel protrudes through defect in abdominal wall adjacent to umbilicus, no covering sac
Not associated with other abnormalities
Complications of gatroschisis?
Carries high risk of dehydration and protein loss
How is gastroschisis treated?
Wrap abdomen in layers of clingfilm
NG tube
IV dextrose
Colloid support for lost protein
Repair of gastroschisis and exomphalos?
Primary closure of abdomen if small
If large, intestine enclosed in a sac sutured to edge of abdominal wall and contents slowly returned to the peritoneal cavity
What is intussusception?
Invagination of proximal bowel into a distal segment, commonly ileum into caecum
When does intussusception present?
Most common intestinal obstruction after neonatal period
3 months - 2 years
Complications of intussusception?
Stretching and constriction of mesentary resulting in venous obstruction and bowel perforation and necrosis
How does intussusception present? (6)
Paroxsymal severe colicky pain and pallor
Refusal to feed
Vomit, may be bile stained
Mass in abdomen
Passing of redcurrant jelly stool with blood stained mucous
Abdominal distension, shock
Investigation of intussusception?
X ray - Distended small bowel, no gas in distal colon or rectum, may show outline
Treatment of intussusception?
Reduction by rectal air insufflation
Operative reduction if failed
What is Meckel’s diverticulum?
Ileal remnant of the vitello-intestinal duct containing ectopic gastric mucosa or pancreatic tissue in 2% of infants
Presentation of Meckel’s diverticulum? (4)
Most asymptomatic
Rectal bleeding
Intusssusception
Diverticulitis
How is Meckel’s diverticulum treated?
Surgical resection
How does malrotation of the bowel present?
Usually in first 1-3 days with obstruction
Presents at any age with volvulus causing obstruction and ischaemic bowel
Symptoms of malrotation?
Bilious vomiting
Abdominal pain and tenderness from peritonitis
Ischaemic bowel
Treatment of malrotation?
GI contrast study and urgent surgery
What is pyloric stenosis?
Hypertrophy of pyloric muscle causing gastric outlet obstruction, presenting between 2-7 weeks and more common in eldest boys
Symptoms of pyloric stenosis? (4)
Projectile vomiting
Dehydration
Loss of interest in feeding
Weight loss
Investigations of pyloric stenosis? (3)
Bloods - hypochloraemic metabolis alkalosis with low sodium and potassium
Test feed - visible gastric peristalsis left to right, palpable olive shaped mass in upper right quadrant
USS
Management of pyloric stenosis?
Correct fluid and electrolyte balance - IV fluids, dextrose
Surgery - pyloromyotomy
Symptoms of constipation? (4)
Decreased frequency of defecation
Hard stool
Pain
Abdominal mass
What is overflow diarrhoea?
Chronic constipation causes rectum to be over distended and the urge to defecate is lost
Involuntary soiling may occur of watery stool
How is constipation treated? (4)
Disimpaction - evacuation of rectum with stool softeners and laxatives and electrolytes (movicol, senna if unsuccessful)
Maintenance - polyethylene glycol, reducing dose over a few months
Enema if severe
Dietary interventions, school support etc.
How do diaphragmatic hernias present?
Antenatally
Failure to respond to resuscitation
Respiratory distress
What is a congenital diaphragmatic hernia?
Defect in the diaphragm so bowel protrudes through and into the lung cavity, compressing the lung
Most are left sided
Signs of congenital diaphragmatic hernia? (2)
Poor air entry on affected side
Apex beat displaced if left sided
Treatment of congenital diaphragmatic hernia?
Surgical correction
High mortality if large pulmonary hypoplasia
What is an inguinal hernia and what causes it?
Protrusion of the bowel through the inguinal canal, mostly indirect
Due to patent processus vaginalis
More common in boys, premature
How does an inguinal hernia present? (2)
Groin/scrotal swelling when crying or straining
Possible scrotal oedema
How are inguinal hernias treated?
Prompt surgical correction to avoid strangulation
What is appendicitis?
Inflammation of the appendix, commonest cause of abdominal pain in children needing surgery
Symptoms of appendicitis? (3)
Anorexia
Vomiting
Initial central colicky pain then localised to right iliac fossa
Signs of appendicitis? (4)
Flushed face
Fever
Pain aggravated on movement
Tenderness and guarding at McBurney’s point
Investigations of appendicitis?
FBC for inflammatory markers
USS
How is appendicitis treated?
Surgery - appendicectomy
Antibiotics if perforation
How common is recurrent abdominal pain in children?
10% of school age
What are some causes of recurrent abdominal pain in children? (13)
IBS IBD Constipation Abdominal migraine Ulcers or functional dyspepsia Malrotation Dysmenorrhoea Ovarian cysts PID Hepatitis Gallstones UTI Psychosocial
What are the 3 most common of recurrent abdominal pain in children?
IBS
Functional dyspepsia
Abdominal migraine
Management of recurrent abdominal pain?
Exclude serious causes
Reassure - 50% become asymptomatic quickly
How common is infective diarrhoea (gastroenteritis)?
10% of under 5s annually
Significant cause of mortality in developing countries
What is the most common cause of gastroenteritis in developed countries?
Rotavirus 60%
Adenovirus, norovirus, coronavirus
What are bacterial causes of gastroenteritis?
Campylobacter jejuni
Shigella, salmonella
Symptoms of gastroenteritis? (3)
Loose watery stools
Vomiting
Dehydration
Red flags in gastroenteritis? (6)
Red flags possibly indicating shock Deteriorating Lethargic Sunken eyes Increased heart rate and respiratory rate Decreased skin turgor
Investigations of gastroenteritis?
Usually none
Stool cultures if septic or bloody stools or if prolonged illness
Check electrolytes
Treatment of gastroenteritis?
Oral rehydration solution
IV fluids if shock or ongoing illness
Antibiotics if septic, if <6 months, if salmonella or C.difficile, if immunodeficient
What is toddler diarrhoea?
Commonest cause of persistent loose stools in preschool children, most grow out of it by 5 but faecal continence may be delayed
Symptoms of toddler diarrhoea?
Stools of varying consistency
Children are well
What causes toddler diarrhoea?
Underlying maturational delay in intestinal motility leading to intestinal hurry
How to manage toddler diarrhoea?
Eat more fat and fibre
If failure to thrive, investigate for cow’s milk allergy or coeliac disease
What is Crohn’s disease?
Inflammatory bowel disease, can affect everywhere from mouth to anus
Symptoms of Crohn’s disease? (11)
Growth failure Delayed puberty Fever Weight loss Abdominal pain Oral lesions Perianal skin tags Uveitis Arthralgia Diarrhoea Erythema nodosum
What is erythema nodosum?
Swollen fat under the skin causing bumps and redness
What is the classic triad of Crohn’s presentation?
Weight loss
Diarrhoea
Abdominal pain
Investigations of Crohn’s disease? (5)
Increased platelets, ESR, CRP Decreased albumin Iron deficiency anaemia Colonoscopy Histology
3 features of Crohn’s disease?
Transmural
Focal - commonly distal ileum/proximal colon
Subacute or chronic
What does colonoscopy in Crohn’s disease show? (4)
Areas of inflamed/thickened bowel
Strictures and fistulae
Narrowed, fissured bowel
Mucosal irregularities
What does histology in Crohn’s disease show?
Non caseating epithelioid cell granulomata
What is the treatment of Crohn’s disease?
Nutritional therapy - replace normal diet with protein feeds for 8 weeks
If ineffective, systemic steroids
If steroids contraindicated, budenoside or 5-ASAs
How is relapsed Crohn’s disease treated?
Immunosuppressants - azathioprine, methotrexate
May need infliximab
Surgery if complicated or refractive
What is ulcerative colitis?
Recurrent inflammatory ulcerating disease affecting colonic mucosa
Symptoms of ulcerative colitis?
Rectal bleeding Diarrhoea Colicky abdominal pain Arthritis Erythema nodosum
How is ulcerative colitis diagnosed?
Bloods - raised inflammatory markers, anaemia
Colonoscopy shows colitis extending from rectum proximally
Histology
What is a feature of ulcerative colitis?
In children, more likely to be pancolitis than confined to distal bowel in adults
What is seen on histology in ulcerative colitis? (4)
Mucosal damage
Crypt loss
Abscesses
Ulceration
How is ulcerative colitis treated? (4)
5-ASA (aminosalicylates)
If only rectum/sigmoid, topical steroids
Azathioprine with prednisolone for exacerbations
Colectomy if severe
What is coeliac disease?
Malabsorption syndrome manifesting as abnormal stools, failure to thrive, nutrient deficiencies
Symptoms of coeliac disease? (4)
Presents between 8-24 months normally, can present less acutely later on
Steatorrhoea (greasy, hard to flush, smell)
Failure to thrive
Abdominal distension
Irritability
What causes coeliac disease?
Gliadin part of gluten provokes damaging immunological response in the proximal small intestine mucosa
Villu shorten leaving a flat mucosa
How is coeliac diagnosed?
Biopsy of small intestine shows villous atrophy and crypt hyperplasia
Serology for IgA tissue transglutaminase antibodies, anti-endomysial
How is coeliac treated?
Lifelong gluten free diet with supervision
What is marasmus?
Severe protein-energy malnutrition in children, with <70% weight for height compared to average
Symptoms of marasmus? (3)
Wasted, wizened appearance
Skinfold thickness and mid-arm circumference reduced
Withdrawn, apathetic
What is Kwashiorkor?
Severe protein malnutrition, common in developing countries where infants are weaned late and diet is high in starch
Symptoms of Kwashiorkor? (8)
Oedema - weight not be as markedly reduced Distended abdomen Hepatomegaly Angular stomatitis Sparse hair Hyperkeratosis, rash Diarrhoea Hypothermia, hypotension, bradycardia
Management of severe malnutrition? (7)
Correct hypoglyaemia Keep warm Correct dehydration Correct electrolytes Treat infection Give vitamins Initiate small volume feeding frequently
What is IBS?
Irritable bowel syndrome, associated with altered GI motility and abnormal sensation, stronger peristaltic contractions
Symptoms of IBS? (5)
Abdo pain relieved by defecation Explosive, loose, mucousy stools Bloating Feeling of incomplete defecation Fluctuating constipation
Treatment of IBS? (5)
Fibre supplements Laxatives Anti-diarrhoeals Antispasmodics - reduce pain Antidepressants - reduce pain
What is colic?
Symptom complex occuring in first few months of life, benign and self limiting
Symptoms of colic?
Paroxysmal inconsolable crying/screaming
Drawing up of knees
Excessive flatus
Causes of colic?
Unknown
Cows milk allergy
GORD
