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Paediatrics: Gastro, urinary + liver Flashcards

1
Q

Clinical presentation of Mesenteric Adenitis

A

Prodrome of viral illness - adenovarius, rhinovirus

Central colicky abdominal pain
Fever
Malaise
Enlarged submandibular lymph nodes

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2
Q

Definition and cause of MeA

A

Intercurrent viral infection causes inflammation of mesenteric lymph nodes.
causative organism: adenovirus, EBV, group B strep

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3
Q

Most common type of inguinal hernia in child and why?

A

Indirect hernia - patent processus vaginalis

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4
Q

What is the difference between indirect and direct inguinal hernia

A

Direct - bowel herniates through posterior wall defect (Hesselbach triangle)
Indirect - bowel herniates through internal ring and often presents in scrotum

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5
Q

What is the classic presentation of an inguinal hernia

A

mass in abdomen, groin or scrotum - prominent when straining or crying
thickened spermatic cord (boys) or round ligament (girls)
nausea + vomiting,

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6
Q

How to differentiate between a reducible and irreducible hernia

A

increase abdominal pressure by pressing on abdomen or asking child to cough.
If it reduces it is most likely direct, if irreducible most likely indirect and at risk of incarceration (presents with vomiting)

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7
Q

What is the management for an incarcerated inguinal hernia

A

Resuscitate with fluids, NBM, NGT, AXR (shows obstruction, gas trapped in hernial sac) –> surgery (division and ligation of hernia)

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8
Q

What is a hydrocele and in which condition does it most commonly occur with?

A

hydrocele a/w inguinal hernia.

Processus vaginalis is too small to allow bowel to pass through, but peritoneal fluid can leak through into scrotum

Presents as B/L painless/non-tender testicular swelling, blue in colour, +ve transillumination

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9
Q

What is the presentation of testicular torsion

A

Sudden onset pain in scrotum, groin, inguinal canal or abdomen,
nausea + vomiting, crying, scrotal skin red and swollen

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10
Q

What is a torted hydatid

A

Hydatid of Morgani is embryological remnant that appears as mass on superior pole or testis

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11
Q

How can you differentiate between testicular torision and a torted hydatid

A

Testicular torsion (presents at adolescents)

  • sudden onset pain in scrotum, groin, inguinal canal or abdomen
  • nausea, vomiting
  • redness and swelling of scrotum

Torted hydatid (presents before puberty in children)

  • gradual onset pain in scrotum, groin, inguinal canal or abdomen
  • Focal tenderness in upper pole of testis
  • Blue dot sign
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12
Q

What is the investigation of hydrocele

A

Transillumination of testis (observe fluid within)

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13
Q

What is the management of testicular torsion

A

Emergency surgery within 6-12h of symptom onset (to save testis and avoid ischaemia)

  • Untwist totted tests
  • Fix both testis (C/L has high risk of also torting)
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14
Q

What are the two investigation of testicular torsion

A
  1. Scrotal examination - observe U/L tenderness and swelling
  2. Doppler US - observe testicular torsion and if blood flow still intact
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15
Q

What is the management of inguinal hernia

A

Opioid analgesia
Aim to reduce hernia (even if irreducible) to reduce oedema
Surgery - ligation and division

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16
Q

When do both testis usually descend

A

Third trimester

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17
Q

What is the referral process for undescended testis

A

Testis not descended at birth - see GP in 6-8 wks
Still not descended - see GP in 3 months
Still not descended - organise surgery before 6 months

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18
Q

What are the investigations for undescended testis

A
  1. Massage (all)
    - retractable testes can be persuaded to lower into scrotum when massaged above groin
    - it is brought back with cremaster reflex
  2. HCG (used for B/L impassable testis)
    - inject IM HCG
    - if testis are present they will cause an increase in testosterone.
    - If there is no increase, seek endocrinologist
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19
Q

What is intussusception and in which age range does this commonly present

A

Enlarged payer’s patch acts as lead point, merges and invaginate onto another section of bowel –> small bowel obstruction –> engorges –> gangrenous –> perforation and peritonitis

6-18 months (peaks at 3 months and 2 years)

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20
Q

How does intussusception present (early and late)

A

Paroxysmal pain:
Acute, sudden onset paroxysmal colic pain a/w pallor and vomiting (child screaming, drawing knees to chest)

Post-pain:
Child exhausted, falls asleep, malaise, dehydrated, refuses feeds

Late: 
Bile stained vomit (obstruction) 
red-current jelly stools (rectal bleed)
abdominal distension (obstruction) 
rebound tenderness (peritonitis)
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21
Q

What is the key finding of intussusception?

A
  1. Abdo exam - sausage shaped mass
  2. USS - target sign
  3. DRE - blood
  4. AXR - bowel obstruction
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22
Q

Treatment of intussusception

A

Resuscitate - plenty of fluids
NBM
NGT
Prophylactic Abx
Radiological reduction by air enema (pneumatic air insufflation to resolve bowel obstruction)
Laporatomy and bowel resection (last line)

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23
Q

What is Meckel’s diverticulum

A

An embryological remamant of omphalomesenteric (vitelline) duct –> forms a diverticulum (mucosal outpouching) in the ileum below the ileocaecal valve (it may have ileal mucosa or gastric or pancreatic)

24
Q

What are the clinical features of Meckel’s diverticulum?

A

NB: clinically indistibguishble from acute appendicitis

  • Mimics appendicitis abdo pain (RIF)
  • Rectal bleeding - fresh + painless
  • Bowel obstruction (abdominal pain, tenderness, distension, constipation, bilious vomit) secondary to volvulus, intussusception, omphalomesenteric band
25
What is a volvulus in paediatrics?
Malrotation of bowel - typically occurs due to Band of Ladd located in the caecum midline which wraps around and constricts the duodenum --> bowel obstruction + ischaemia
26
What are the clinical features
Bowel obstruction - Bilious green vomiting - Constipation - partial or absolute (faeces ± flatus) - Abdo pain, distension, tenderness - eventual peritonitis if not treated
27
What are the investigative findings of volvulus?
USS or barium swallow contrast AXR shows constriction at duodenum
28
What is toddler's diarrhoea and how does it present?
Delayed maturation of the bowel - has no relation to malabsorption Occurs between 6months - 5 years Presentation - Abdo colicky pain + tenderness - Increased flatus - Diarrhoea - undigested foods - Healthy child, growing normally
29
How do you manage toddler's diarrhoea?
1. Reassurance and school advice - self-limiting, resolves by age 5 2. Diet - Increase fats (slows intestinal motility), normalise fibre, decrease milk, sugars, fruit juices 3. Loperamide may be required
30
What are the symptoms and signs of constipation and impaction?
``` Constipation - faeces, usually flatus okay Low frequency Abdominal pain Soiling - indicates impaction Eventually reduced flatus Mass felt on abdominal exam ```
31
What is the 1st line treatment for constipation and impaction in children?
Laxatives: - Combined - Movicol (common) - Stool softener (osmotic) - Lactulose, Docusate - Stimulant - Senna
32
What is Hirschsprungs disease and how does it present?
Lack of ganglion cells in the myenteric and submucosal plexus of bowel causes contracted bowel followed by normally innervated dilated colon Presentation (GAMES FC): - Green bilious vomiting - gross Abdominal distension - Meconium not passed in 24hrs - Enterocolitis (secondary c.diff) - Stool ejection upon DRE - FTT - Constipation (most common symptom)
33
How is Hirschsprung's diagnosed and treated?
Rectal biopsy diagnosis Treatment of rectal washout and anorectal pull through procedure
34
What are the common causative organisms of gastroenteritis?
Viral (common) - Rotavirus (60%), adenovirus (15%) | Bacterial - Campylobacter, shigella, E.coli, cholera
35
What are the common features of gastroenteritis? What are the red flag features indicating dangerous causative organism?
Diarrhoea (lasts 7 d, resolves 2wks) - Increased frequency - Loose consistency Vomiting (lasts 2 d, resolves 1 wk) - Non-bilious - Causes dehydration (increased skin turgor, CRT, HR; decreased BP; dry mucous membranes; sunken eyes) Severe - Blood stool - invasive bacteria like E.Coli 0157, Shigella - Rice water stool - Cholera - Fever - Shigella
36
What are the key investigations and management of child with gastroenteritis?
Investigation 1. Stool culture 2. Blood culture 3. Screen for HUS Management 1. ORS - 50ml/kg over 4hrs 2. Bolus fluids - 20ml/kg 3. Abx only if confirmed bacterial 4. Zinc treatment - developing countries
37
What is a key electrolyte complication of excessive vomiting?
Hyper-natraemia - Jittery movements - Hyper-reflexia - Increased tone - Convulsions - Coma
38
What are the symptoms of GORD?
Gastrointestinal - Effortless ejection of milk + stomach contents - Irritable - FTT - Heart burn - if old enough - Oesophagitis - heart burn, odynophagia, dysphagia, haematemesis Respiratory - Cough, hoarseness, stridor, apnoea Neuro - Sandifer's syndrome - abnormal hyper-extension and lateral rotation of neck
39
What is the key management of GORD? Note: start simple
1. Info + reassurance - sit baby up after eating, do not overfeed, wind baby during and after feed, position baby at 30 degrees whilst nursing 2. Dietary advice - Thickened feeds - carobel - Small frequent meals - Avoid citrus, spicy, fatty foods; carbonated drinks; caffeine; food before bed 3. Drugs - H2 antagonist - ranitidine - PPI - omeprazole - Gaviscon - Domperidone (A/E) last line 4. Surgery - Nissens fundoplication
40
What are the possible investigations for GORD?
1. 24hr oesophageal pH study 2. Barium contrast swallow w/ fluoroscopy or nuclear medicine milk study - identify structural abn 3. Endoscopy and biopsy
41
What are the symptoms of acute appendicitis?
Classic (60%) - Central abdominal pain, colicky, exacerbated by movement - Nausea, vomiting, diarrhoea - Fever (mild) + fatigue - Voluntary guarding - Flushed Late - RIF pain (McBurney's point) - Rebound tenderness (peritonitis) - Rovsing sign (palpate LIF and RIF hurts) - Mucous coated faeces - Swinging pyrexia
42
In whom is appendicitis most common?
10-20 year olds | 1 in 6 people get acute appendicitis
43
What is the key management for acute appendicitis?
ABCDE 1. Fluids, 0.9% Saline if dehydrated from vomiting 2. Abx - Amoxicillin, Gentamicin, Metronidazole 3. Surgery - Appendectomy
44
What investigative findings might you have with acute appendicitis?
NB: diagnosis is made upon clinical presentation 1. Urine sample - pyuria (WCC), bacteriuria (nitrates) 2. USS - inflammation of appendix if visible
45
What are the possible complications of acute appendicitis?
Perforation Abscess Mass Ileus
46
What are the key signs and symptoms of pyloric stenosis?
- Projectile vomiting < 1hr after feeds - Hungry --> dehydration --> loss of interest in food - Olive shaped mass in epigastric region - Decreased UO and frequency/volume of stools - Jaundice Late - FTT or weight loss - Coffee ground vomit - Haematemesis from oesophagitis
47
What are the key investigative findings of pyloric stenosis?
1. ABG - Metabolic alkalosis showing low K+/Cl- 2. U+Es - Low K+, Cl-, Na+ 3. Test feed - Calms baby and shows peristalsis 4. NGT (Ryles) aspiration of gastric contents - Allows palpation of olive shaped mass 5. USS - Confirms diagnosis
48
What is the treatment for a patient presenting with pyloric stenosis?
ABCDE 1. Fluids - 0.9% Saline - 20ml/kg if bolus or 100x10kg, 50x10kg, 20x1kg for maintenance 2. Ramstedt procedure
49
At what age does pyloric stenosis typically present and in whom is it most common?
First 7 weeks of life | Males (4:1)
50
When does coeliac disease present typically?
When causative foods (wheat, rye, oats and barely) are brought into diet i.e. 6-24 months
51
What is the presentation of a child with coeliac disease?
Floating stools - fatty, pale, foul smelling Anaemia due to B12/Folate deficiency FTT and weight loss Muscle wasting - buttocks Gross motor developmental delay and arthralgia Delayed puberty Ascites and peripheral oedema
52
What is the management of coeliac disease?
Dietary change (1st line) - replace causative foods with rice, tapioca, corn and potatoes - signs of adherence and improvement are serology -ve, TTG IgA Ab return to normal, improved histology
53
What is the management of coeliac disease?
Dietary change (1st line) - replace causative foods with rice, tapioca, corn and potatoes - signs of adherence and improvement are serology -ve, TTG IgA Ab return to normal, improved histology Gluten challenge - at 2 years old, test food with gluten to see if still sensitive - Before -ve serology, after +ve serology
54
What is the surgical management of cryptorchidism?
Orchidoplexy at 6 months
55
Where are most undescended testis found
80% palpable at the external inguinal ring | 20% impassable when lying intra-abdominally
56
What is the common age range for mesenteric amenities and acute appendicitis?
MeA < 15 years | Acute appendicitis 10-20 yo
57
What is the management for mesenteric adenitis?
Self-limiting due to viral infection 1. Observation - important to differentiate from MeA and acute appendicitis - Acute appendicitis symptoms progress - MeA symptoms static 2. Bloods - Leukocytosis 3. Laporotmy - May see inflamed mesenteric lymph nodes - Common cause of normal appendectomy

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