Paediatrics- Gastro Flashcards
Medical Causes of Abdominal Pain
- Constipation is also very common
- Urinary tract infection
- Coeliac disease
- Inflammatory bowel disease
- Irritable bowel syndrome
- Mesenteric adenitis
- Abdominal migraine
- Pyelonephritis
- Henoch-Schonlein purpura
- Tonsilitis
- Diabetic ketoacidosis
- Infantile colic
Medical Causes of Abdominal Pain
There are addition causes in adolescent girls:
- Dysmenorrhea (period pain)
- Mittelschmerz (ovulation pain)
- Ectopic pregnancy
- Pelvic inflammatory disease
- Ovarian torsion
- Pregnancy
Surgical Causes of Abdominal Pain
- Appendicitis causes central abdominal pain spreading to the right iliac fossa
- Intussusception causes colicky non-specific abdominal pain with redcurrant jelly stools
- Bowel obstruction causes pain, distention, absolute constipation and vomiting
- Testicular torsion causes sudden onset, unilateral testicular pain, nausea and vomiting
Red Flags for Serious Abdominal Pain
- Persistent or bilious vomiting
- Severe chronic diarrhoea
- Fever
- Rectal bleeding
- Weight loss or faltering growth
- Dysphagia (difficulty swallowing)
- Nighttime pain
- Abdominal tenderness
Abdominal Pain
Initial investigations that may indicate the pathology pathology:
- Anaemia can indicate inflammatory bowel disease or coeliac disease
- Raised inflammatory markers (ESR and CRP) can indicate inflammatory bowel disease
- Raised anti-TTG or anti-EMA antibodies indicates coeliac disease
- Raised faecal calprotectin indicates inflammatory bowel disease
- Positive urine dipstick indicates a urinary tract infection
Recurrent abdominal pain often corresponds to stressful life events, such as
loss of a relative or bullying. The leading theory for the cause is increased sensitivity and inappropriate pain signals from the visceral nerves (the nerves in the gut) in response to normal stimuli.
Abdo Pain
Management involves careful explanation and reassurance. Measures that can help manage the pain are:
- Distracting the child from the pain with other activities or interests
- Encourage parents not to ask about or focus on the pain
- Advice about sleep, regular meals, healthy balanced diet, staying hydrated, exercise and reducing stress
- Probiotic supplements may help symptoms of irritable bowel syndrome
- Avoid NSAIDs such as ibuprofen
- Address psychosocial triggers and exacerbating factors
- Support from a school counsellor or child psychologist
Abdominal Migraine
What is this
Children are more likely than adults to suffer with a condition called abdominal migraine. This may occur in young children before they develop traditional migraines as they get older. Abdominal migraine presents with episodes of central abdominal pain lasting more than 1 hour. Examination will be normal.
Abdominal Migraine may be associated with
- Nausea and vomiting
- Anorexia
- Pallor
- Headache
- Photophobia
- Aura
Management of abdominal migraine is similar to migraine in adults. Careful explanation and education is important. It involves treating acute attacks and preventative measures. Preventative medications are initiated by a specialist.
Treating the acute attack:
Low stimulus environment (quiet, dark room)
Paracetamol
Ibuprofen
Sumatriptan
Whar are some Preventative medications used for abdominal migraine
Pizotifen, a serotonin agonist
Propranolol, a non-selective beta blocker
Cyproheptadine, an antihistamine
Flunarazine, a calcium channel blocker
Pizotifen is the main preventative medication to remember for abdominal migraine. It needs to be withdrawn slowly when stopping as it is associated with withdrawal symptoms such as depression, anxiety, poor sleep and tremor.
Constipation in children is a very common problem in paediatrics. Most cases of constipation can be described as __________ constipation or _________ constipation,
Constipation in children is a very common problem in paediatrics. Most cases of constipation can be described as idiopathic constipation or functional constipation,
It is important to think about possible secondary causes of constipation, such as
- Hirschsprung’s disease
- Cystic fibrosis (particularly meconium ileus)
- Hypothyroidism
- Spinal cord lesions
- Sexual abuse
- Intestinal obstruction
- Anal stenosis
- Cows milk intolerance
Typical features in the history and examination that suggest constipation are:
- Less than 3 stools a week
- Hard stools that are difficult to pass
- Rabbit dropping stools
- Straining and painful passages of stools
- Abdominal pain
- Holding an abnormal posture, referred to as retentive posturing
- Rectal bleeding associated with hard stools
- Faecal impaction causing overflow soiling, with incontinence of particularly loose smelly stools
- Hard stools may be palpable in abdomen
- Loss of the sensation of the need to open the bowels
WHat does Encopresis mean
Encopresis is the term for faecal incontinence. This is not considered pathological until 4 years of age. It is usually a sign of chronic constipation where the rectum becomes stretched and looses sensation. Large hard stools remain in the rectum and only loose stools are able to bypass the blockage and leak out, causing soiling.
Other rarer causes of encopresis include:
- Spina bifida
- Hirschprung’s disease
- Cerebral palsy
- Learning disability
- Psychosocial stress
- Abuse
There are a number of lifestyle factors that can contribute to the development and continuation of constipation:
- Habitually not opening the bowels
- Low fibre diet
- Poor fluid intake and dehydration
- Sedentary lifestyle
- Psychosocial problems such as a difficult home or school environment (always keep safeguarding in mind)
What is Desensitisation of the Rectum
Often patients develop a habit of not opening their bowels when they need to and ignoring the sensation of a full rectum. Over time they loose the sensation of needing to open their bowels, and they open their bowels even less frequently. They start to retain faeces in their rectum. This leads to faecal impaction, which is where a large, hard stool blocks the rectum. Over time the rectum stretches as it fills with more and more faeces. This leads to further desensitisation of the rectum. The longer this goes on, the more difficult it is to treat the constipation and reverse the problem.
Red flags are things in the history or examination that should make you think about serious underlying conditions that may be causing the constipation. These should prompt further investigations and referral to a specialist:
- Not passing meconium within 48 hours of birth (cystic fibrosis or Hirschsprung’s disease)
- Neurological signs or symptoms, particularly in the lower limbs (cerebral palsy or spinal cord lesion)
- Vomiting (intestinal obstruction or Hirschsprung’s disease)
- Ribbon stool (anal stenosis)
- Abnormal anus (anal stenosis, inflammatory bowel disease or sexual abuse)
- Abnormal lower back or buttocks (spina bifida, spinal cord lesion or sacral agenesis)
- Failure to thrive (coeliac disease, hypothyroidism or safeguarding)
- Acute severe abdominal pain and bloating (obstruction or intussusception)
Constipation Complications
- Pain
- Reduced sensation
- Anal fissures
- Haemorrhoids
- Overflow and soiling
- Psychosocial morbidity
Management of constipation
NICE clinical knowledge summaries recommend:
- Correct any reversible contributing factors, recommend a high fibre diet and good hydration
- Start laxatives (movicol is first line)
- Faecal impaction may require a disimpaction regimen with high doses of laxatives at first
- Encourage and praise visiting the toilet. This could involve scheduling visits, a bowel diary and star charts.
Laxatives should be continued long term and slowly weaned off as the child develops a normal, regular bowel habit.
Gastro-oesophageal reflux is where contents from the stomach reflux through the ______ ___________ _________ into the oesophagus, throat and mouth.
Gastro-oesophageal reflux is where contents from the stomach reflux through the lower oesophageal sphincter into the oesophagus, throat and mouth.
How is GORD developed in babies
In babies there is immaturity of the lower oesophageal sphincter, allowing stomach contents to easily reflux into the oesophagus. It is normal for a baby to reflux feeds, and provided there is normal growth and the baby is otherwise well this is not a problem, however it can be upsetting for parents. This usually improves as they grow and 90% of infants stop having reflux by 1 year.
GORD
It is normal for babies to have some reflux after larger feeds. It becomes more troublesome when this causes them to become distressed. Signs of problematic reflux include:
- Chronic cough
- Hoarse cry
- Distress, crying or unsettled after feeding
- Reluctance to feed
- Pneumonia
- Poor weight gain
Children over one year may experience similar symptoms to adults, with heartburn, acid regurgitation, retrosternal or epigastric pain, bloating and nocturnal cough.
Vomiting is very non-specific and is often not indicative of underlying pathology. Some of the possible causes of vomiting include:
- Overfeeding
- Gastro-oesophageal reflux
- Pyloric stenosis (projective vomiting)
- Gastritis or gastroenteritis
- Appendicitis
- Infections such as UTI, tonsillitis or meningitis
- Intestinal obstruction
- Bulimia
Vomitting
Red Flags
Certain features in the history should make you think about serious underlying problems:
- 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
Management for GORD
In simple cases some explanation, reassurance and practical advice is all that is needed. Advise:
- Small, frequent meals
- Burping regularly to help milk settle
- Not over-feeding
- Keep the baby upright after feeding (i.e. not lying flat)
More problematic cases of GORD can justify treatment with
- Gaviscon mixed with feeds
- Thickened milk or formula (specific anti-reflux formulas are available)
- Ranitidine
- Omeprazole where ranitidine is inadequate
GORD management
Rarely in severe cases they may need further investigation with a ______ ____ and ________. Surgical ___________ can be considered in very severe cases, however this is very rarely required or performed.
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.
WHat is Sandifer’s Syndrome
This is a rare condition causing brief episodes of abnormal movements associated with gastro-oesophageal reflux in infants. The infants are usually neurologically normal.
Sandifer’s Syndrome
Key features
- 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
Sandifer’s Syndrome
management
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.
What is pyloric sphincter
The pyloric sphincter is a ring of smooth muscle the forms the canal between the stomach and the duodenum.
Hypertrophy (thickening) and therefore narrowing of the pylorus is called
pyloric stenosis.
This prevents food traveling from the stomach to the duodenum as normal.
Pyloric stenosis
WHat causes “projectile vomiting”
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”
Features of
Pyloric stenosis
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.
Diagnosis of pyloric stenosis
abdominal ultrasound to visualise the thickened pylorus.
Management of pyloric stenosis
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.
What is Acute gastritis
is inflammation of the stomach and presents with nausea and vomiting
WHat does Enteritis mean
is inflammation of the intestines and presents with diarrhoea.
Gastroenteritis is
inflammation all the way from the stomach to the intestines and presents with nausea, vomiting and diarrhoea.
is most common cause of gastroenteritis bacterial/viral/fungal
viral
Gastroenteritis
It is essential to ________ the patient in any healthcare environment, such as a paediatric assessment unit or hospital ward, as they can easily spread it to other patients.
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.
What is the main concern with gastroenteritis?
Dehydration
Management for gastroenteritis
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.
Key conditions to think about in patients with loose stools are:
- Infection (gastroenteritis)
- Inflammatory bowel disease
- Lactose intolerance
- Coeliac disease
- Cystic fibrosis
- Toddler’s diarrhoea
- Irritable bowel syndrome
- Medications (e.g. antibiotics)
