Paediatrics- Gastro Flashcards

Question

Vomiting is very non-specific and is often not indicative of underlying pathology. Some of the possible causes of vomiting include:

Answer 1

* Overfeeding * Gastro-oesophageal reflux * Pyloric stenosis (projective vomiting) * Gastritis or gastroenteritis * Appendicitis * Infections such as UTI, tonsillitis or meningitis * Intestinal obstruction * Bulimia

Answer 2

* **Not keeping down any feed** (pyloric stenosis or intestinal obstruction) * **Projectile or forceful vomiting** (pyloric stenosis or intestinal obstruction) * **Bile stained** vomit (intestinal obstruction) * **Haematemesis or melaena** (peptic ulcer, oesophagitis or varices) * **Abdominal distention** (intestinal obstruction) * **Reduced consciousness**, bulging fontanelle or neurological signs (meningitis or raised intracranial pressure) * **Respiratory symptoms** (aspiration and infection) * **Blood in the stools** (gastroenteritis or cows milk protein allergy) * **Signs of infection** (pneumonia, UTI, tonsillitis, otitis or meningitis) * **Rash, angioedema** and other signs of allergy (cows milk protein allergy) * **Apnoeas** are a concerning feature and may indicate serious underlying pathology and need urgent assessment

Answer 3

* Small, frequent meals * Burping regularly to help milk settle * Not over-feeding * Keep the baby upright after feeding (i.e. not lying flat)

Answer 4

* Gaviscon mixed with feeds * Thickened milk or formula (specific anti-reflux formulas are available) * Ranitidine * Omeprazole where ranitidine is inadequate

Answer 5

Rarely in severe cases they may need further investigation with a **barium meal** and **endoscopy.** Surgical **fundoplication** can be considered in very severe cases, however this is very rarely required or performed.

Answer 6

This is a rare condition causing brief episodes of abnormal movements associated with gastro-oesophageal reflux in infants. The infants are usually neurologically normal.

Answer 7

* **Torticollis:** forceful contraction of the neck muscles causing twisting of the neck * **Dystonia:** abnormal muscle contractions causing twisting movements, arching of the back or unusual postures

Answer 8

The condition tends to resolve as the reflux is treated or improves. Generally the outcome is good. It is worth referring patients with these symptoms to a specialist for assessment, as the differential diagnosis includes more serious conditions such as **infantile spasms (West syndrome) and seizures.**

Answer 9

The pyloric sphincter is a ring of smooth muscle the forms the canal between the stomach and the duodenum.

Answer 10

pyloric stenosis. This prevents food traveling from the stomach to the duodenum as normal.

Answer 11

After feeding, there is increasingly powerful peristalsis in the stomach as it tries to push food into the duodenum. Eventually it becomes so powerful that it ejects the food into the oesophagus, out of the mouth and across the room. This is called “projectile vomiting”

Answer 12

Pyloric stenosis typically presents in the first few weeks of life, with a hungry baby that is thin, pale and generally **failing to thrive**. The classic description of vomiting you should remember for your exams is **“projectile vomiting”**. If examined after feeding, often the peristalsis can be seen by observing the abdomen. A firm, round mass can be felt in the upper abdomen that **“feels like a large olive”**. This is caused by the **hypertrophic** muscle of the **pylorus**. Blood gas analysis will show a **hypochloric** (low chloride) **metabolic alkalosis** as the baby is vomiting the **hydrochloric acid** from the stomach. This is a common data interpretation question in exams, so worth remembering.

Answer 13

abdominal ultrasound to visualise the thickened pylorus.

Answer 14

Treatment involves a **laparoscopic pyloromyotomy** (known as “**Ramstedt’s operation“**). An incision is made in the smooth muscle of the pylorus to widen the canal allowing that food to pass from the stomach to the duodenum as normal. **Prognosis** is excellent following the operation.

Answer 15

is inflammation of the stomach and presents with nausea and vomiting

Answer 16

is inflammation of the intestines and presents with diarrhoea.

Answer 17

inflammation all the way from the stomach to the intestines and presents with nausea, vomiting and diarrhoea.

Answer 18

It is essential to **isolate** the patient in any healthcare environment, such as a paediatric assessment unit or hospital ward, as they can easily spread it to other patients.

Answer 19

Dehydration

Answer 20

The key to management is establishing whether they are able to keep themselves **hydrated** or whether they need admission for **IV fluids.** Antibiotics are generally not recommended or required. Most children make a full recovery with simple supportive management, but beware gastroenteritis can potentially be fatal, especially in very young or vulnerable children with other health conditions.

Answer 21

* Infection (gastroenteritis) * Inflammatory bowel disease * Lactose intolerance * Coeliac disease * Cystic fibrosis * Toddler’s diarrhoea * Irritable bowel syndrome * Medications (e.g. antibiotics)

Answer 22

greasy stools with excessive fat content. This suggests a problem with digesting fats, such as pancreatic insufficiency **(think about cystic fibrosis).**

Answer 23

* Rotavirus * Norovirus Adenovirus is a less common cause and presents with a more subacute diarrhoea.

Answer 24

E. coli 0157 produces the **Shiga toxin** Shiga toxin destroys blood cells and leads to **haemolytic uraemic syndrome (HUS).**

Answer 25

The use of antibiotics increases the risk of haemolytic uraemic syndrome, therefore antibiotics should be avoided if **E. coli** gastroenteritis is considered.

Answer 26

Campylobacter

Answer 27

* Raw or improperly cooked poultry * Untreated water * Unpasteurised milk

Answer 28

Abdominal cramps Diarrhoea often with blood Vomiting Fever

Answer 29

Antibiotics can be considered after isolating the organism where patients have severe symptoms or other risk factors such as HIV or heart failure. Popular antibiotic choices are **azithromycin or ciprofloxacin.**

Answer 30

spread by faeces contaminating drinking water, swimming pools and food. he incubation period is 1 to 2 days and symptoms usually resolve within 1 week without treatment. bloody diarrhoea, azithromycin or ciprofloxacin.

Answer 31

spread by eating raw eggs or poultry, or food contaminated with the infected faeces of small animals. Incubation is 12 hours to 3 days and symptoms usually resolve within 1 week diarrhoea that can be associated with mucus or blood Antibiotics are only necessary in severe cases and should be guided by stool culture and sensitivities.

Answer 32

The typical exam patient with bacillus cereus develops symptoms soon after eating leftover fried rice that has been left at room temperature. It has a short incubation period after eating the rice before symptoms occur, and they recover within 24 hours. Examiners like this question because the course of bacillus cereus is easy to distinguish from the other causes of gastroenteritis, so if you remember one cause of gastroenteritis this is probably the most likely to come up in exams

Answer 33

Pigs eating raw or undercooked pork

Answer 34

It is also spread through contamination with the urine or faeces of other mammal such as rats and rabbits.

Answer 35

Appendicitis

Answer 36

**enterotoxins** when growing on food such as eggs, dairy and meat

Answer 37

Giardia lamblia is a type of microscopic **parasite.** It lives in the **small intestines** of mammals

Answer 38

This is called faecal-oral transmission

Answer 39

metronidazole

Answer 40

Antidiarrhoeal medication such as **loperamide** and antiemetic medication such as **metoclopramide** are generally not recommended.

Answer 41

Lactose intolerance Irritable bowel syndrome Reactive arthritis Guillain–Barré syndrome

Answer 42

Coeliac disease is an autoimmune condition where exposure to gluten causes an immune reaction that creates inflammation in the small intestine. It usually develops in early childhood but can start at any age.

Answer 43

anti-tissue transglutaminase (anti-TTG) and anti-endomysial (anti-EMA Deaminated gliadin peptides antibodies (anti-DGPs)

Answer 44

Inflammation affects the small bowel, particularly the **jejunum**. It causes **atrophy** of the intestinal villi.

Answer 45

* Failure to thrive in young children * Diarrhoea * Fatigue * Weight loss * Mouth ulcers * Anaemia secondary to iron, B12 or folate deficiency * Dermatitis herpetiformis is an itchy blistering skin rash that typically appears on the abdomen

Answer 46

Peripheral neuropathy Cerebellar ataxia Epilepsy

Answer 47

Remember that we test all patients with a new diagnosis of **type 1 diabetes** for coeliac disease, even if they don’t have symptom, because the conditions are often linked.

Answer 48

HLA-DQ2 gene (90%) HLA-DQ8 gene

Answer 49

Check total immunoglobulin A levels to exclude IgA deficiency before checking for coeliac disease specific antibodies: * Raised anti-TTG antibodies (first choice) * Raised anti-endomysial antibodies Endoscopy and intestinal biopsy show: * “Crypt hypertrophy” * “Villous atrophy”

Answer 50

Type 1 diabetes Thyroid disease Autoimmune hepatitis Primary biliary cirrhosis Primary sclerosing cholangitis Down’s syndrome

Answer 51

* Vitamin deficiency * Anaemia * Osteoporosis * Ulcerative jejunitis * Enteropathy-associated T-cell lymphoma (EATL) of the intestine * Non-Hodgkin lymphoma (NHL) * Small bowel adenocarcinoma (rare)

Answer 52

A lifelong gluten free diet is essentially curative. Relapse will occur on consuming gluten again. Checking coeliac antibodies can be helpful in monitoring the disease.

Answer 53

**N** – No blood or mucus (these are less common in Crohns.) **E** – Entire GI tract **S** – “Skip lesions” on endoscopy **T** – Terminal ileum most affected and Transmural (full thickness) inflammation **S** – Smoking is a risk factor (don’t set the nest on fire) Crohn’s is also associated with weight loss, strictures and fistulas.

Answer 54

**C** – Continuous inflammation **L** – Limited to colon and rectum **O** – Only superficial mucosa affected **S** – Smoking is protective **E** – Excrete blood and mucus **U** – Use aminosalicylates **P** – Primary sclerosing cholangitis

Answer 55

Suspect inflammatory bowel disease in children and teenagers presenting with **perfuse diarrhoea, abdominal pain, bleeding, weight loss or anaemia**. They may be systemically unwell during flares, with fevers, malaise and dehydration.

Answer 56

Finger clubbing Erythema nodosum Pyoderma gangrenosum Episcleritis and iritis Inflammatory arthritis Primary sclerosing cholangitis (ulcerative colitis)

Answer 57

Blood tests for anaemia, infection, thyroid, kidney and liver function. A raised CRP indicates active inflammation. **Faecal calprotectin** is released by the intestines when inflamed. It is a useful screening test and is more than 90% sensitive and specific for IBD in adults. **Endoscopy** (OGD and colonoscopy) with biopsy is the gold standard investigation for diagnosis of IBD. **Imaging** with ultrasound, CT and MRI can be used to look for complications such as fistulas, abscesses and strictures.

Answer 58

First line are steroids **(e.g. oral prednisolone or IV hydrocortisone).** If steroids alone don’t work, consider adding immunosuppressant medication under specialist guidance: * Azathioprine * Mercaptopurine * Methotrexate * Infliximab * Adalimumab

Answer 59

Azathioprine Mercaptopurine Aminosalicylate (e.g. mesalazine oral or rectal) UC

Answer 60

When the disease only affects the distal ileum it is possible to surgically resect this area to prevent further flares. Crohn’s typically involves the entire GI tract. Surgery can also be used to treat strictures and fistulas secondary to Crohn’s disease.

Answer 61

Inducing Remission Mild to moderate disease * First line: aminosalicylate (e.g. mesalazine oral or rectal) * Second line: corticosteroids (e.g. prednisolone) Severe disease * First line: IV corticosteroids (e.g. hydrocortisone) * Second line: IV ciclosporin

Answer 62

Ulcerative colitis usually only affects the colon and rectum. Therefore, removing the colon and rectum (panproctocolectomy) will remove the disease. The patient is then left with either a permanent ileostomy or something called an ileo-anal anastomosis (J-pouch). This is where the ileum is folded back on itself and fashioned into a larger pouch that functions like a rectum. This “J-pouch” is then attached to the anus and collects stools prior to the person passing a motion.

Answer 63

Biliary atresia is a congenital condition where a section of the **bile duct** is either narrowed or absent. This results in **cholestasis**, where the bile cannot be transported from the liver to the bowel. **Conjugated bilirubin** is excreted in the bile, therefore biliary atresia prevents the excretion of conjugated bilirubin.

Answer 64

Biliary atresia presents shortly after birth with significant **jaundice** due to high conjugated bilirubin levels.

Answer 65

The initial investigation for possible biliary atresia is **conjugated and unconjugated** bilirubin. A **high proportion of conjugated bilirubin** suggests the liver is processing the bilirubin for excretion (by conjugating it), but it is not able to excrete the conjugated bilirubin because it cannot flow through the biliary duct into the bowel.

Answer 66

Management of biliary atresia is with surgery. The “**Kasai portoenterostomy”** involves attaching a section of the small intestine to the opening of the liver, where the bile duct normally attaches. This is somewhat successful and can clear the jaundice and prolong survival. Often patients require a full liver transplant to resolve the condition.

Answer 67

Intestinal obstruction is where a physical obstruction prevents the flow of faeces through the intestines. This blockage will lead to a back-pressure through the gastrointestinal system, causing vomiting. It also causes absolute constipation, where the patient is unable to pass stools or wind.

Answer 68

* Meconium ileus * Hirschsprung’s disease * Oesophageal atresia * Duodenal atresia * Intussusception * Imperforate anus * Malrotation of the intestines with a volvulus * Strangulated hernia

Answer 69

* Persistent vomiting. This may be bilious, containing bright green bile. * Abdominal pain and distention * Failure to pass stools or wind * Abnormal bowel sounds. **These can be high pitched and “tinkling” early in the obstruction and absent later.**

Answer 70

The initial investigation of choice is an **abdominal xray.** This may show **dilated loops of bowel** proximal to the obstruction and collapsed loops of bowel distal to the obstruction. There will also be **absence of air in the rectum.**

Answer 71

Patients presenting with intestinal obstruction need to be referred to a **paediatric surgical unit** as an emergency. Initial management involves making them **nil by mouth** and inserting a **nasogastric tube** to help drain the stomach and stop the vomiting. They will also require **IV fluids** to correct any dehydration and electrolyte imbalances, and keep them hydrated while waiting for definitive management of the underlying cause.

Answer 72

Hirschsprung’s disease is a congenital condition where nerve cells of the **myenteric plexus are absent** in the distal bowel and rectum. The myenteric plexus, also known as **Auerbach’s plexus**, forms the enteric nervous system. It is the brain of the gut.

Answer 73

* Downs syndrome * Neurofibromatosis * Waardenburg syndrome (a genetic condition causing pale blue eyes, hearing loss and patches of white skin and hair) * Multiple endocrine neoplasia type II

Answer 74

The severity of the presentation and the age at diagnosis varies significantly depending on the individual and the extent of the bowel that is affected. It can present with acute intestinal obstruction shortly after birth or more gradually developing symptoms: * Delay in passing meconium (more than 24 hours) * Chronic constipation since birth * Abdominal pain and distention * Vomiting * Poor weight gain and failure to thrive

Answer 75

**toxic megacolon** and **perforation of the bowel**. It requires urgent **antibiotics, fluid resuscitation and decompression of the obstructed bowe**l.

Answer 76

**Abdominal xray** can be helpful in diagnosing intestinal obstruction and demonstrating features of HAEC. **Rectal biopsy** is used to confirm the diagnosis. The bowel histology will demonstrates an absence of ganglionic cells. Unwell children and those with enterocolitis will require initial **fluid resuscitation** and management of the intestinal obstruction. IV antibiotics are required in HAEC. Definitive management is by **surgical removal of the aganglionic section of bowel**

Answer 77

Intussusception is a condition where the bowel **“invaginates” or “telescopes”** into itself. Picture the bowel folding inwards. This thickens the overall size of the bowel and narrows the lumen at the folded area, leading to a palpable mass in the abdomen and obstruction to the passage of faeces through the bowel. It typically occurs in infants 6 months to 2 years and is more common in boys.

Answer 78

* Concurrent viral illness * Henoch-Schonlein purpura * Cystic fibrosis * Intestinal polyps * Meckel diverticulum

Answer 79

* Severe, colicky abdominal pain * Pale, lethargic and unwell child * **“Redcurrant jelly stool”** * Right upper quadrant mass on palpation. This is described as “sausage-shaped” * Vomiting * Intestinal obstruction

Answer 80

Look out for the “**redcurrant jelly stool**” in your exams as this indicates intussusception as a diagnosis. The other classic feature is the **sausage-shaped mass** in the abdomen. The typical child in the exam will have had a **viral upper respiratory tract infection** preceding the illness and will have features of intestinal obstruction (vomiting, absolute constipation and abdominal distention). **Ultrasound** is the initial investigation of choice.

Answer 81

Diagnosis is made mainly by **ultrasound** scan or contrast enema. **Therapeutic enemas** can be used to try to reduce the intussusception. Contrast, water or air are pumped into the colon to force the folded bowel out of the bowel and into the normal position. **Surgical reduction** may be necessary if enemas do not work. If the bowel becomes **gangrenous** (due to a disruption of the blood supply) or the bowel is perforated, then **surgical resection** is required.

Answer 82

Obstruction Gangrenous bowel Perforation Death

Answer 83

* **central abdominal pain,** that moves down to the right iliac fossa (RIF) over time and eventually becomes localised in the RIF. * **Tenderness in McBurney’s point.** * Loss of appetite (anorexia) * Nausea and vomiting * Rovsing’s sign (palpation of the left iliac fossa causes pain in the RIF) * Guarding on abdominal palpation * Rebound tenderness is increased pain when quickly releasing pressure on the right iliac fossa * Percussion tenderness is pain and tenderness when percussing the abdomen * Rebound tenderness and percussion tenderness suggest peritonitis, caused by a ruptured appendix.

Answer 84

This is a localised area one third the distance from the anterior superior iliac spine (ASIS) to the umbilicus.

Answer 85

Diagnosis is based on the **clinical presentation and raised inflammatory markers.** Performing a CT scan can be useful in confirming the diagnosis, particularly where another diagnosis is more likely. An **ultrasound scan** is often used in female patients to exclude ovarian and gynaecological pathology. When a patient has a **clinical presentation** suggestive of appendicitis but investigations are negative, the next step is to perform a **diagnostic laparoscopy** to visualise the appendix directly. The surgeon can then proceed to an appendicectomy during the same procedure if indicat

Answer 86

* Ectopic Pregnancy * Ovarian Cysts * Meckel’s Diverticulum * Mesenteric Adenitis * Appendix Mass

Answer 87

Removal of the inflamed appendix **(appendicectomy)** is the definitive management for acute appendicitis. **Laparoscopic surgery** is associated with fewer risks and faster recovery compared to open surgery (laparotomy).

Answer 88

* Bleeding, infection, pain and scars * Damage to bowel, bladder or other organs * Removal of a normal appendix * Anaesthetic risks * Venous thromboembolism (deep vein thrombosis or pulmonary embolism)