Paediatrics - Gastro Flashcards
4 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
Abdominal pain is a very common presentation in children. These can be split into non-organic causes, medical causes and surgical causes. Non-organic or functional abdominal pain is very common in children over 5 years. This is where no disease process can be found to explain the pain.
What are the red flag symptoms that suggest 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
What do the following investigations findings indicate in someone with abdominal pain?
Initial investigations that may indicate the pathology pathology:
Anaemia
Raised inflammatory markers (ESR and CRP)
Raised anti-TTG or anti-EMA antibodies
Raised faecal calprotectin
Positive urine dipstick
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
What causes recurrent abdominal pain and how is it managed?
A diagnosis of recurrent abdominal pain is made when a child presents with repeated episodes of abdominal pain without an identifiable underlying cause. The pain is described as non-organic or functional. This is common and can lead to psychosocial problems, such as missed days at school and parental anxiety. There is overlap between the diagnoses of recurrent abdominal pain, abdominal migraine, irritable bowel syndrome and functional abdominal pain.
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.
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
A 5 year child expieriences recurrent episodes of central abdominal pain, naseu and vomitting. Typically these episodes last a few hours. What is the likely cause?
Management?
prophalaxis medication?
Abdominal Migraine
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.
There may be associated:
Nausea and vomiting
Anorexia
Pallor
Headache
Photophobia
Aura
Treating the acute attack - same as adult migraine:
Low stimulus environment (quiet, dark room)
Paracetamol
Ibuprofen
Sumatriptan
Prophalaxis
- Pizotifen - a seotnin antagonist
Constipation in children is a very common problem in paediatrics.
How often someone opens their bowels varies between individuals. This is even more variable in breast-fed babies, which can have as little as one stool a week. Someone opening their bowels daily may be constipated, whereas someone opening their bowels twice a week may not, if that is normal for them.
What are some of the Typical features in the history and examination that suggest constipation?
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 is encopresis
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 (faecal impaction) 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
KEY
What is the most common cause of constipation?
Red flag symptoms for secondary causes - likely diagnosis?:
Not passing meconium within 48 hours of birth
Neurological signs or symptoms
Vomiting
Ribbon stool
Abnormal anus
Abnormal lower back or buttocks
Failure to thrive
Acute severe abdominal pain and bloating**
Most cases of constipation can be described as idiopathic constipation or functional constipation, meaning there is not a significant underlying cause other than simple lifestyle factors. It is important to think about possible secondary causes of constipation, such as Hirschsprung’s disease, cystic fibrosis or hypothyroidism.
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)
Secondary Causes:
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)
Key - management of idiopathic 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 (macrogol same as laxido))
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 lower oesophageal sphincter into the oesophagus, throat and mouth.
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.
When is reflux in infants concerning?
How does reflux present in older children?
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.
List some some of the possible causes of vomiting?
What do the following red flag of vomitting indicate?
- not keeping down any food
- projectile/forceful vomitting
- bile stained
- haematemesis
- ahdominal distention
- reduced conciousness, bulging fontanele or neurological signs
- respiratory symptoms
- signs of infection
- rash, angioedma
- apnoeas
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
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
How is GORD managed in children, including babies
Ix?
- for simple cases - lifestyle advice (small frequent meals, burping to settle milk, keeping upright after feeding)
- Gaviscon (alginate - form a layer) mixed with feeds
- Thickened milk or formula (specific anti-reflux formulas are available)
- Omeprazole - if required
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 - rare
This is a rare condition causing brief episodes of abnormal movements associated with gastro-oesophageal reflux in infants. The infants are usually neurologically normal. The key features are:
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
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.
A two week old neonate presents with fialure to thrive (not putting on weight) and projectile vomiting. On examination you feel a firm round mass in the upper abdomen.
Diagnosis?
What does blood gas show?
Investigation?
Management?
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”.
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.
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”.
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.
Ix - abdominal ultrasound to visualise the thickened pylorus.
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 Hirshprung’s disease - pathophysiology?
Hirschsprung’s disease is a congenital condition where parasympathetic ganglion cells of the myenteric plexus are absent in the distal bowel and rectum.
The length of colon without innervation varies between patients from a small area to the entire colon. When the entire colon is affected this is called total colonic aganglionosis.
The aganglionic section of colon does not relax, causing it to becomes constricted. This leads to loss of movement of faeces and obstruction in the bowel. Proximal to the obstruction the bowel becomes distended and full - THIS WAS TESTED (KINDA) THE BOWEL IS DISTENDED, then constrited distally.
Family history is signifcant. Associated with down’s syndrome, neurofribmatosis, waardenburg syndrome and multiple endocrine neoplasia type ii - i would bother learning this…
Background:
The myenteric plexus, also known as Auerbach’s plexus, forms the enteric nervous system. This nerve plexus runs all the way along the bowel in the bowel wall, and is a complex web of neurones, ganglion cells, receptors, synapses and neurotransmitters. It is responsible for stimulating peristalsis of the large bowel. Without this stimulation the bowel looses it’s motility and stops being able to pass food along its length.
During fetal development these cells start higher in the GI tract and gradually migrate down to the distal colon and rectum. Hirschsprung’s occurs when the parasympathetic ganglion cells do not travel all the way down the colon, and a section of colon at the end is left without these parasympathetic ganglion cells.
