Paediatrics: Gastroenterology Flashcards
what are the 3 general categories for causes of abdominal pain?
- Functional
- Medical
- Surgical
What does it mean when something is a functional disorder?
No disease process found to explain the pain (lack of pathology)
Name some medical causes of abdominal pain?
- Constipation
- UTI
- Coeliac disease
- IBD
- Abdo migraine
- Hoch-schonlein Purpura
- pyelonephritis
Name some surgical causes of abdominal pain? (4)
- Appendicitis
- Intussusception
- Bowel obstruction
- Testicular torsion
What additional causes could there be for abdominal pain in girls? (6)
- Pregnancy
- PID
- Dysmenorrhoea
- Mittelschmerz
- Ectopic pregnancy
- Ovarian torsion
name some red flags for a presentation of abdominal pain?
- Persistent or bilious vomiting
- Severe chromic diarrhoea
- Fever
- Rectal bleeding
- Weight loss
- Dysphagia
Px presenting with abdominal pain is found to anaemic. What could this indicate? (2)
- Inflammatory bowel disease
- Coeliac
(I think due to iron deficiency- failure to absorb in duodenum/proximal jejunem)
Px presenting with abdominal pain is found to have raised inflammatory markers. What could this indicate?
IBD (or infection I guess)
Px presenting with abdominal pain is found to have raised anti-TTG/ anti-EMA . What could this indicate?
coeliac
Px presenting with abdominal pain is found to have raised feacal calprotectin. What could this indicate?
IBD
Px presenting with abdominal pain is found to have positive urine dipstick . What could this indicate?
UTI
what is the most common cause of constipation?
functional
name some secondary causes of constipation? (4)
- Hirschprungs
- CF
- Hypothyroidism
- drug induced
name some symptoms of constipation? (7)
- <3 stools per week (though this can be normal)
- hard stools that are hard to pass
- Rabit dropping stools
- Straining
- Abdo pain
- Rectal bleeding
- Hard stool palpate in abdo
What lifestyle factors can contribute to constipation ? (5)
- Habitually not opening bowels
- Low fibre diet
- Poort fluid intake
- Sedentary lifestyle
- Pscycosocial problems/stress
Describe how constipation causes desensitisation of the rectum and what this causes?
ignore sensation of full rectum => loses sensation => more infrequent bowel openings => faecal impaction => encopresis
Constipation red flag: what could not passing meconium in first 48 hrs indicate? (2)
- CF
- Hirschprungs disease
Constipation red flag: what could constipation plus neurological symptoms indicate?
CP
Constipation red flag: what could constipation plus vomiting indicate? (2)
- Hirschprungs disease
- Bowel obstruction
Constipation red flag: what could constipation plus ribbon stool indicate?
anal stenosis
Constipation red flag: what could constipation plus failure to thrive indicate? (3)
- Coeliac disease
- Hypothyroidism
- Safeguarding concern
Constipation red flag: what could constipation plus sever abdominal pain indicate?
- Intussusception
- Obstruction
What percentage of infants posset?
40%
What is Gastro-Oesophageal Reflux?
It is where the contest of the stomach reflux through the lower oesophageal sphincter into the oesophagus, throat + mouth
why are babies prone to reflux?
babies have immature lower oesophageal sphincter so quite normal (as long as the baby can grow)
What pathophysiology explain GOR? (3)
- Short, narrow oesophagus
- Delayed gastric emptying
- High fluid diet
RF for GOR? (3)
- Prematurity
- Parental Hx
- Obesity
When does GOR become problematic
when symptomatic
- Chronic cough
- Hoarse cry
- Distress after feeding or reluctant to feed
- Pneumonia
- Poor weight gain
How to older children present with GOR?
similar to adults
- Heartburn
- Regurgitation
- Bloating
- Noctural cough
Causes of vomiting in babies?
- Overfeeding
- GOR
- Pyloric stenosis
- Gastritis
- Infection (UTI, Meningitis)
- raised ICP
what advice can you give for GORD?
- Small meals
- Do not overfeed
- Burp the baby
- Keep upright after feeding
Apart from advice, what is the management for GORD?
- Gaviscon mixed with water immediately after feeds
- PPI
what percentage of GOR presentations will spontaneously resolve within first yr of life?
90%
pyloric stenosis pathophysiology?
Narrowing of the pylorus => gastric outlet restriction => prevents normal passage of food from stomach to duodenum => powerful peristalsis => food return to oesophagus => powerful projectile vomiting
What causes pyloric stenosis?
hypertrophy and thickening of pylorus => stenosis
what are where is the pyloric sphincter?
ring off mouth muscle that forms canal between stomach + duodenum
pyloric stenosis RF?
- Male
- FHx
Describe the presentation of pyloric stenosis? at what age?
usually presents in first few weeks (4-6 weeks)
- Hungry baby that its hit, pale + failure to thrive
- non-bilious PROJECTILE vomiting after every feed
- Weight loss dehydration
What might be found on examination of a patient with pyloric stenosis? (2)
- Visible peristalsis
- Palpable olive-sized pyloric mass
what would the blood gas of a Px with pyloric stenosis show (+ electrolytes) ? explain
- Hypochloric + hypokalaemia metabolic alkalosis
- Vomit HCl => increase pH
- low H+ => kidneys exchange K to retain H+ => hypokalaemia
What investigations for pyloric stenosis ? god standard?
- Blood test
- Abdominal US (gold standard):
what would be seen on AUSS in pyloric stenosis?
hypertrophic pyloric muscles
Management of pyloric stenosis?
Surgical - Laparoscopic pyeloromyotomy (widen canal of pylorus)
What is acute gastritis ? presents with?
Inflammation of the stomach
- Presents with nausea + vomiting
What is enteritis? Presents with?
Inflammation of the intestines
- Presents with diarrhoea
What is gastroenteritis? presents with?
Inflammation all the way form the stomach to the intestines so presents with Nausea + vomiting + diarrhoea
Usual prognosis of gastroenteritis ?
very common and usually self limiting
Most common cause of gastroenteritis ?
usually viral (norovirus or rotavirus)
Name a common bacterial cause of gastroenteritis ?
E.Coli
what strain of E. coli is particularly concerning? why?
E.Coli 0147
- produces Shiga toxin
what does the Shiga toxin cause? complication? produces by what organism ?
produced by E.Coli + shigella
- abdo cramps + bloody diarrhoea
- Haemolytic uraemic syndrome
what determines if a patient needs to be admitted with gastroenteritis s?
Hydration
- Need to work out if Px can self hydrate of if IV fluids are required
Name some things to consider for a diarrhoea differential?
- Infection
- IBD
- Coeliac
- Lactose intolorance
- Coeliac
- CF
- IBS
- Abx
Management of Gastroenteretitis ?
- Immediate isolate to preven spear to other Px, barrier nursing, children stay off school
- Stool culture
- Maintain good hydration: fluid challenge, IV
- Usually viral so self limiting
When are gastroenteritis patients given Abx?
only given to Px at risk of ocmplciaitons or once causative ogaisn has been identified
name some complications of gastroenteritis?
- Lactose intolorance
- IBS
- Reactive arthritis (Reiters syndrome)
- Guillian barre syndrome
A patient presents after having eaten leftover fried rice left out at room temp and then developed abdo cramping + vomiting + watery diarrhoea. What is the likely pathogen?
Bacillus cereus
What is Coeliac disease?
Lifelong gluten sensitive autoimmune disease of the small intestine (leading to inflam of small intestine)
Describe the pathophysiology of coeliac disease?
autoantibodies are produced in response to exposure to gluten => target epithelial cells of small intestine
Which 2 autoantibodies are associated with coeliac disease? what type of antibody?
IgA antibodies
- Anti-tissue transflutaminase (anti-TTG)
- Anti-endomysial (Anti-EMA)
Where does the inflammation in coeliac disease mainly effect?
jejunum
What genetic predisposition is associated with coeliac disease?
HLA-DQ2/DQ8
what is the chance of of PX to develop coeliac disease if they have the genetic predisposition ? if they don’t?
HLA-DQ2/DQ8
- negative value is almost 100%
- most ppl with these genes do NOT develop coeliac
what is the presentation of coeliac disease?
- Failure to thrive
- Diarrhoea
- Fatigue
- Mouth ulcers
What other disease should you always test for if you consider coeliac disorder?
type 1 diabetes
(they are closely linked)
How do you diagnose coeliac disease? gold standard?
while patient is on gluten-containing diet
- Check total IgA levels
- Anti TTG and anti-EMA
- Endoscopy and duodenal biopsy
Why test total IgA levels for coeliac diagnosis?
to exclude IgA deficiency (to make sure result will be valid)
What will be seen on duodenal biopsy in coeliac disease?
- Crypt hypertrophy
- Villous atrophy
Coeliac management ?
lifelong gluten free diet
What cell mediated autoumme response occurs in coeliac disease?
T-cell mediated
What is IBD?
Inflammatory Bowel Disease
- Umbrella term for 2 main disease causing inflammation of GI tract (Crohn’s, Ulcerative Colitis)
What pneumonic helps remember symptoms of Crohns ?
crows NESTS
What pneumonic helps remember details of UC?
U-C-CLOSEUP
What does NESTS Stand for? which condition?
Crohns
- No blood or mucus (less common)
- Entire GI tract (gum to bum)
- Skip lesions
- Transmural (full thickness inflam), Terminal ileum
- Smoking is RF (Don’t set the nest on fire)
where does Crohns usually affect?
Terminal ileum but can be anywhere gum=> bum
what can transmural inflam in crohns lead to?
full thickness inflammation => produces deep ulcers + fissures (cobblestone appearance)
What does CLOSEUP stand for? which condition?
- Continuous inflammation (no skip lesions)
- Limited to colon and rectum
- Only superficial mucosa affected
- Smoking protective
- Excretion of blood and mucus
- Use aminosalicylate
- Primary sclerosis cholangitis (associated with UC)
IBD presentation?
- suspect in children presenting with diarrhoea, abdo pain, bleeding, weight loss, anaemia
- Flare ups: Fever, malaise, dehydration
What testing would you do for suspected IBD? gold standard?
- Stool sample: faecal cal protective (released by intestines with inflamed)
- Stool microscopy + culture: -ve to exclude infection as differential
= Endoscopy: plus multiple intestinal biopsies (gold standard)
What microscopic changes would be seen in crnohs intestinal biopsy?
non-caseating granulomatous inflammation
What microscopic changes would be seen in UC intestinal biopsy?
- Crypt abscess formation
- reduced goblet cells
- Non-granulomatous
Why would you do a CT or USS in IBD?
look for complications (fistulas, abscesses + strictures)
What is the general management of IBD?
- Referral to secondary care + MDT approach (+dieticien )
- Monitor growth and pubertal development
- Induce remission
- maintain remission (meds not always taken)
Describe the management in crohns ?
- Induce remission: steroids (oral prednisone or IV hydrocortisone), consider immunosuppression: azathioprine
- Maintain remission: azathioprine, surgery
when would surgery be a good idea of crohns?
if only affects distal ileum then can remove to preven further flares
Complication of Crohns disease?
sever exacerbations may be life-threatening
- Severe systemmtic supet
- Bowel perforation
- intestinal obstruction
- Abcess formation
- Fistulas
- Strictures
- mortality
describe the management of UC?
- Inducing remission: aminosalicylate or coricosteroids
- Maintain remission: amionsalisylate, surgery (removal of colon + rectum will remove disease)
Complication of UC?
life threatening I flare ups
- sever systemic upset
- toxic megacolon
- colonic performation
- Bowel adenocarcinoma
- mortality
what is biliary atresia? aetiology?
Congenital condition where section of bile duct is narrowed or absent
Biliary atresia pathophysiology? what it causes?
bile duct obstruction => cholestasis => bile cannot be traposrted form liver to the bowel
biliary atresia prevents the excretion of what? be specific
conjugated bilirubin
- conjugated billirbin is excreted in bile so biliary atresia prevent CB excretion
How does Biliary atresia usually present? when?
presents shortly after birth with significant jaundice
High levels of what cause the symptoms of biliary atresia?
high levels of CB cause jaundice
What investigations might you do for suspected biliary atresia? results? explain
- Conjugated + unconjugated bilirubin: high proportion CB (suggest that liver is processing but unable to excrete)
Management of biliary atresia
surgical management
- bile duct construction of full liver transplant (rarer)
What is intestinal obstruction? what does it cause? explain
A physical obstruction prevents flow of faeces through intestines => back pressure + vomiting + absolute consiptation
What is absolute constipation ?
unable to pass stools or wind
Name some causes of Intestinal obstruction ? (6)
- Meconium ileus
- Hirschprungs disease
- oesophageal/doudenal atresia
- intussusception
- imperforate anus
- malrotation of intestines (with volvulus)
Bowel obstruction presentation?
- Persistent vomiting
- abdo pain + distention
- absolute constipation
- Abnormal bowel sounds
describe the vomit in BO
bilious, persistent
describe the bowel sounds in BO (2) what do they mean?
- high pitched + tinkling (early)
- absent (late sign)
How would you diagnose intestinal obstruction?
AXR
What would you see on AXR of Px with BO ? (3)
- Dilated loops of bowel proximal to obstruction
- Collapsed loop of bowel distal to obstruction
- Absence of air in rectum
Describe the management of BO? in the meantime ? why each thing
surgical emergency
- nil my mouth
- NG tube to empty stomach + stop vomiting
- IV fluids to correct fluid + electrolytes
while awaiting definitive management
What is intussusception ?
telescoping/invagination of one part of the bowel onto the other
Peak age incidence of intussusception?
peak incidence is between 5 - 7 months of age (rare to occur after 2 years)
- just lil babies then
at what location are 90% of intussusception along GI tract?
ileo-colic type
(distal ileum passes into caecum through ileocaecal valve)
Name some RF for intussusception ? (3)
- Meckel diverticulum (most common)
- Polyps
- HSP
Name the buzzword parts to intussception Hx ?
- sudden onset inconsolable cry
- red-current consistency stools
- drawing up knees
- pallor
what condition presents with red-current consistency stools ? why is this?
intussusception
- due to presence of blood + mucus
What would you find on examination of Px with intussusception ?
- abdo distention
- Palpable mass (RUQ)
- signs of peritonitis
Are bowel sounds present in intussusception?
yes (or abscent I think)
describe the mass that might be palpable in intussuscpeton? where?
palpable sausage-shaped mass (RLQ - oleo-caecal)
what should you consider in the differential for intussusception?
- COlic
- Testicular torsion
- Appendicitis
- Gastroentiritis
- Volvulus
How would you diagnose intussusception?
- Abdo US (Target sign I think)
Describe the management of intussusception?
Surgical management
- If signs of shock/dehydration: fluid resus
- non operative: air or contrast enema
- surgical reduction
Complications of intussusception ?(3)
- Obstruction
- Perforation
- Dehydration + shock
What is hirschprungs disease (HD)? explain it?
congenital ganglionic megacolon disease
Describe the pathophysiology of HD? where is affect (specific)
congenital disease where ganglionic cells of the mesenteric plexus fail to develop in the distal bowel => absence of parasympathetic ganglion cells (sections of colon left without) => delayed or failed passage of meconium
What is another name for th mesenteric plexus? name a congenital condition that affects this?
auerbachs plexus
- Hirschprungs disease
what does the mesenteric plexus do? where is it located?
enteric nervous system responsible for peristalsis
Describe the classic triad presentation of HD?
- Failure to pass meconium
- Abdo distention
- Bilious vomiting
overall presentation of HD?
- delay in passing meconium (>24 hrs), chronic constiaption
- abdo distension + pain
- billious vomiting
^ classic triad - poor weight gain
- failure to thrive
HD investigations ? what is require to confirm diagnosis - what will this show?
- AXR
- Rectal biopsy (required for diagnosis): will shows absence of ganglionic cells)
what is the definitive management of HD?
surgical removal of aganglionic section
explain a serious complication associated with Hirschprungs disease? management ?
- hirschprungs associated enterocolitis: inflam + obstruction of intestine => toxic megacolon + perforation
- Management: requires Abx, fluid rhesus and decompression of obstruction bowel
What is appendicitis?
Inflammation of the appendix
what is the appendix?
small thin tube sprouting from the caecum
Describe the pathophysiology of appendicitis? explain how lead to complication
diret luminal obstruction => commensal bacteria multiply => acute inflam + reduced venous drainage => ischaemia => necrosis => perforation => release faecal contents + infective material into abdo => peritonitis
At what age is peak incidence of appendicitis ?
10 - 30 years
what 2 things can lead to direct luminal obstruction in appendicitis (2 most common) ?
- secondary to faecolith
- lymphoid hyperplasia
describe the presentation of appendicitis? time course?
abdo pain starting at umbilicus which then moves to RIF
- anorexia, nausea + vomiting
What could be found OE of appendicitis?
- Tenderness at MrBurneys point
- Rovsings sing
- Guarding
- Rebound tenderness
- Percussions tenderness
where is McBurneys point?
1/3 the distance from ASIS to umbilicus
what finding might indicate peritonitis ? O/E (3)
- Guarding
- Rebound tenderness
- Percussion tenderness
how do you diagnosis appendicitis? what investigations?
based on clinical findings + raised inflam markers
- US often used in females
- urinalysis (assess renal or urological causes)
name some other important differentials for appendicitis?
- Ectopic pregnancy (do pregnancy test)
- Ovarian cyst
- decks diverticulum
- mesenteric addenitis appendic mass
What is an appendix mass? caused by what?
When momentum sticks to inflamed appendix => RIF mass
Describe the management of appendicitis?
Removal of inflamed appendix (appendicectomy)
what complications are associated with all surgeries? (7)
- Bleeding
- Infection
- Pain
- Scars
- Unsuccessful
- damage to other organs
- anaesthesia
describe what the word Gastroschisis means (pre + suffix)
gastro (GI tract)
schisis (separation)
what is Gastroschisis? what does this lead to?
anterior abdominal wall fails to close so remains open (separated) throughout fetal development => abdo organs protrude out to outside environment?
which oran is usually affected in gastroshcisis?
intestines
describe anatomically where Gastroschisis protrudes? usually?
full thickness of abdominal wall defect
- the the R of umbilicus
What can happen in Gastroschisis in utero? what does this cause?
organs protrude out => exposure to amniotic fluid => intestines irritated + inflamed => malabsorption
After delivery: what protects the protruded organs in Gastroschisis ?
nothing
- organs exposed to air = no peritoneal layer
RF for Gastroschisis ?
- young maternal age < 20
- Maternal alcohol and tobacco use
How could Gastroschisis be diagnosed antenatally ? what finding?
antenatal: US, blood test (increased MSAFP)
at birth: its visible
Gastroschisis Management? immediate? definitive?
Immediate: fluid resus, maintain temp, sterile clear covering
- Surgery: organs put back in body and defect repaired
Generally what is Gastroschisis vs omphacocele ?
G: open, R of umbilicus
O: closed, central
What is omphacocele ?
congenital abdo wall defect at insertion of umbilical cord => abdo contents herniate outside the abdo within a membranous sac
what 2 layers does the memebransou sac surround omphacocele have?
peritoneum
amnion
omphacocele pathophysiology ?
though to be failure of normal intestinal migration of physiological umbilical herniation
omphacocele RF?
- maternal age >40
- Maternal smoking/drinking/SSRI use
omphacocele investigations?
- Increased alphafetoprotein
- USS
what does increased alpha fetoprotein antenatally suggest?
routinely measure in antenatal screening and is typically elevated in abdo wall defects
omphacocele management ? immediate? definitive?
immediate: protect member, ensure adequate hydration and temp
- surgical: primary closure
What is cows milk protein allergy (CMPA) ?
immune mediated allergic reaction to proteins in cows milk
What immunoglobulin may CMPA be associated with?
IgE (can also be non-IgE mediated or mixed)
What type of hypersensitivity reaction is CMPA?
type 1
which protein trigger the reaction in CMPA?
casein and whey (cows milk proteins)
what are the response time to IgE and non-IgE mediated CMPA?
- IgE: rapid response (withhin 2 hrs)
- Non-IgE: slower (occuring over several days)
CMPA RF?
- Formula fed babies
- Personal Hx of atopy
how old are kids with CMPA?
<3
(usually grow out of it by 3 yrs)
CMPA presentation?
- GI symptoms
- General allergic symptoms
name some CMPA GI symptoms ?
- Bloating + wind
- Abdo pain
- Diarrhoea
- Vomiting
Name some CMPA allergic symptoms:
- Rash (hives)
- angio-oedema
- Cough or wheeze
- sneezing
- Watery eyes
- Eczema
- If severe (rare): anaphylaxis
how is CMPA allergy diagnosis made?
based on H + E
CMPA management ? formula? breast?
avoid cows milk
- Breast feeding mothers should avoid dairy
- Replace formula with hydrolysed formula (contains cows milk by proteins broken down so no immune response)
Difference between cows milk intolerance and allergy ?
intolerance is not allergic response as no immune response
- both can have similar GI symptoms but intolerance has no allergic symptoms
What type of drink should ideally be avoided until diarrhoea is resolved
fruit juice
What dermatological skin condition is associated with coeliac disease? distribution ?
Dermatitis herpetiformis
- rash with red raised patches (commonly seen on elbows, knees and buttocks)
What is a hernia ?
protrusion of viscus through a defect of the walls of its containing cavity
what are the 2 types of inguinal hernia ? describe them ?
- Indirect inguinal hernia: bowel herniate through inguinal canal into the scrotum (due to incomplete closure of processes vaginalis)
- Direct inguinal: due to weakness in the abdo wall
which inguinal hernia type most common in kids ?
indirect inguinal hernia
where does direct inguinal hernia occur ? anatomical landmark ?
hesselbach triangle
(this hernia is more common in adults)
differential for limp in inguinal region ? scrotal region ?
scrotal: hydrocele, varicolcele
- inguinal: femoral hernia, lymph node, undescended testes/ectopici
inguinal hernia presentation ?
groin swelling plus
- N+V
- constipation
- abdo pain
inguinal hernia management ?
clinical diagnosis
consider USS
surgical repair
what causes kwashiorkor ? deficiency of what ?
oedematous malnutrition
- lack of protein in diet => oedema
what is Meckel diverticulum ? affecting where ?
Meckel’s diverticulum is a malformation of the distal ileum that occurs in around 2% of the population
Meckel diverticulum Px ? (4) can cause what ? (2)
- asymptomattic
- but can bleed, become inflamed, rupture
- can cause: volvulus, intussception
Meckel diverticulum Mx ?
often removed prophylactically if identified in other abdominal surgeries
what is toddlers diarrhoea ? and what could cause it ? (3)
chronic nonspecific diarrhea of childhood
- excessive fluid intake
- large amount of fruit juice (lots of sugar)
- immature digestive tract
