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Paediatrics > Paediatrics Gastroenterology > Flashcards

Paediatrics Gastroenterology Flashcards

1
Q

What are the causes of abdo pain in children?

A

Non-organic or functional (most common in children over 5)

Medical

Surgical

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2
Q

What are some medical causes of abdo pain?

A

Constipation is very common

UTI

Coeliac disease

IBD

IBS

Mesenteric adenitis

Adbominal migraine

Pyelonephritis

Henoch-Schonlein purpura

Tonsilitis

Diabetic ketoacidosis

Infantile colic

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3
Q

What are the additional causes of abdo pain in adolescent girls?

A

Dysmenorrhoea (period pain)

Mittelschmerz (ovulation pain)

Ectopic pregnancy

Pelvic inflammatory disease

Ovarian torsion

Pregnancy

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4
Q

What are some surgical causes of abdominal pain?

A

Appendicitis - central abso pain spreading to right iliac fossa

Intussusception - colicky non-specific abdo pain with redcurrant jelly stools

Bowel obstruction - pain, distention, absolute constipation and vomiting

Testicular torsion - sudden onset, unilateral testicular pain, nausea and vomiting

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5
Q

Name some red flags for serious abdominal pain?

A

Persistent or bilious vomiting

Severe chronic diarrhoea

Fever

Rectal bleeding

Weight loss or faltering growth

Dysphagia (difficulty swallowing)

Nighttime pain

Abdo tenderness

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6
Q

What initial investigations for abdo pain in children?

A

Anaemia for IBD or Coeliacs

Raised inflammatory markers (ESR and CRP) for IBD

Raised anti-TTG or anti-EMA antibodies for coeliac disease

Raised faecal calprotectin for IBD

Positive urine dipstick for UTI

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7
Q

How is recurrent abdo pain diagnosed in children?

A

Repeated episodes of abdo pain without an identifiable underlying cause (pain is non-organic or functional)

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8
Q

What is the result of recurrent abdo pain?

A

Missed days at school and parental anxiety

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9
Q

What abdo diagnoses overlap?

A

Recurrent abdo pain

Abdo migraine

IBS

Functional abdo pain

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10
Q

What often causes recurrent abdo pain?

A

Stressful life events (loss of relative / bullying)

Theory that its caused by signals from the visceral nerves (the nerves in the gut) with increased sensitivity and inappropriate pain signals

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11
Q

What is the management of recurrant abdo pain?

A

Explanation and reassurance:

  • Distracting the child from the pain with other activities
  • Encourage parents not to ask about the pain
  • Advice about sleep, regular meals, healthy balanced diet, staying hydrated, exercise and reducing stress
  • Probiotic supplements may help symptoms of IBS
  • Avoid NSAIDs e.g. ibuprofen
  • Address psychosocial triggers and exacerbating factors
  • Support from child psychologist
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12
Q

What is an abdominal migraine?

A

Episodic central abdo pain lasting more than 1 hour (examination will be normal) - may occur in young children before they develop traditional migraines as they get older

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13
Q

What is associated with an abdominal migraine?

A
  • Nausea and vomiting
  • Anorexia
  • Pallor
  • Headache
  • Photophobia
  • Aura
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14
Q

What is the general management of abdominal migraine?

A

Similar to adults - careful explanation and education is important

Treating acute attacks

Preventative measures

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15
Q

How to treat the acute attacks in abdominal migraine?

A

Low stimulus environment (quiet, dark room)

Paracetamol

Ibuprofen

Sumatriptan

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16
Q

What are some preventative medications against abdominal migraines?

A

Pizotifen, a serotonin agonist (main one - needs to be withdrawn slowly due to withdrawal - depression, anxiety, poor sleep, tremor)

Propanolol non selective beta blocker

Cyproheptadine, antihistamine

Fluarazine a CCB

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17
Q

What are most cases of constipation caused by?

A

Idiopathic or functional (not a significant cause other than lifestyle factors)

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18
Q

How often may breast fed babies open their bowels?

A

As little as once a week (this is normal)

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19
Q

What are the typical features which suggest constipation?

A
  • Less than 3 stools a week
  • Hard stools, difficult to pass
  • Rabbit dropping stool
  • Straining and painful passage of stools
  • Abdominal pain
  • Retentive posturing
  • Rectal bleeding associated with hard stools
  • Faecal impactation causing overflow soiling with incontinence of particularly loose smelly stools
  • Hard stools palpable in abdomen
  • Loss of sensation of the need to go for stools
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20
Q

What is encopresis?

A

Faecal incontinence (not pathological until 4 years of age) usually a sign of chronic constipation where rectum becomes stretched and looses sensation

Large hard stools remain in rectum whereas loose stools are able to bypass the blockage and leak out, causing soiling

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21
Q

What are some rarer causes of encopresis?

A
  • Spina bifida
  • Hirschprung’s disease
  • Cerebral palsy
  • Learning disability
  • Psychosocial stress
  • Abuse
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22
Q

What lifestyle factors can cause constipation?

A
  • Habitually not opening the bowels
  • Low fibre diet
  • Poor fluid intake and dehydration
  • Sedentary lifestyle
  • Psycosocial e.g. difficult home / school environment (always keep safeguarding in mind)
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23
Q

What causes desensitisation of the rectum?

A

Habit of not opening bowels = loose sensation of needing to open bowels - retain faeces in rectum causing faecal impactation where large hard stools block the rectum leading to desensitisation

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24
Q

What are some secondary causes of constipation?

A

Hirschsprung’s disease

Cystic fibrosis (particularly meconium ileus)

Hypothyroidism

Spinal cord lesions

Sexual abuse

Intestinal obstruction

Anal stenosis

Cows milk intolerance

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25
Q

What are the red flags for constipation?

A

Not passing meconium within 48 hours of birth (cystic fibrosis or Hirschsprung’s disease)

Neurological signs 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)

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26
Q

What are some complciations of constipation in children?

A

Pain

Reduced sensation

Anal fissures

Haemorrhoids

Overflow and soiling

Psychosocial morbidity

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27
Q

When can a diagnosis of idiopathic constipation be made?

A

Without investigations, provided red flags are considered

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28
Q

How to manage constipation in children?

A
  • Correct any reversible contributing factors, recommend a high fibre diet and good hydration
  • Start laxatives (movicol is first line)
  • Disimpactation regimen for faecal impactation with high doses of laxatives at first
  • Encourage and praise visiting the toilet (schedule visits, bowel diary and start charts)

Laxatives continued long term and slowly weaned off as child develops normal, regular bowel habit

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29
Q

What is gastro-oesophageal reflux?

A

Contents from stomach reflux through the lower oesophageal sphincter

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30
Q

Why do babies have more reflux?

A

Immaturity of the lower oesophageal sphincter (90% of infants stop having reflux by 1 year)

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31
Q

What are some signs of problematic reflux?

A
  • Chronic cough
  • Hoarse cry
  • Distress, crying or unsettled after feeding
  • Reluctance to feed
  • Pneumonia
  • Poor weight gain
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32
Q

What are the symptoms of GORD in children over 1 year?

A

Similar to adults with heartburn, acid regurgitation, retrosternal or epigastric pain, bloating and nocturnal cough

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33
Q

What are the causes of vomiting?

A

Overfeeding

Gastro-oesophageal reflux

Pyloric stenosis (projective vomiting)

Gastritis or gastroenteritis

Appendicitis

Infections such as UTI, tonsillitis or meningitis

Intestinal obstruction

Bulimia

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34
Q

What are some red flags for reflux?

A

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

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35
Q

What is the management for simple cases of reflux?

A
  • Small, frequent meals
  • Burping regularly to help milk settle
  • Not over-feeding
  • Keeping baby upright after feeding (i.e. not lying flat)
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36
Q

What do more problematic cases of GORD get treated with?

A

Gaviscon mixed with feeds

Thickened milk or formula (specific anti-reflux formulas are available)

Omeprazole where ranitidine is inadequate (not ranitidine as its banned)

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37
Q

What further investigation is there for GORD?

A

Barium meal and endoscopy

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38
Q

What is the treatment for severe GORD?

A

Surgical fundoplication

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39
Q

What is Sandifer’s syndrome?

A

Rare condition causing brief episodes of abnormal movements associated with GORD in infants - normally neurologically normal

  • Torticollis
  • Dystonia (abnormal muscle contractions causing twisting movements, arching of the back or unusual postures)

Condition resolves as reflux is treated or improves

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40
Q

What are the differentials of Sandifer’s syndrome?

A

Infantile spasms (West syndrome) and seizures

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41
Q

What is the pyloric sphincter?

A

Ring of smooth muscle between stomach and duodenum?

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42
Q

What is pyloric stenosis?

A

Hypertrophy (thickening) of the pylorus

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43
Q

What does pyloric stenosis typically cause?

A

Projectile vomiting (due to increasing power peristalsis of the stomach as it tries to push food into the duodenum)

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44
Q

What are the features of pyloric stenosis?

A
  • First few weeks of life
  • Baby is pale, thin and failing to thrive
  • Projectile vomiting
  • Lump like large olive in upper abdomen caused by hypertrophic muscle of the pylorus
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45
Q

What will blood gas analysis show for pyloric stenosis?

A

Hypochloric (low cholride) metabolic alkalosis as the baby is vomiting the hydrochloric acid from the stomach

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46
Q

How is pyloric stenosis diagnosed?

A

Abdominal ultrasound to visualise the thickened pylorus

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47
Q

What is the treatment of pyloric stenosis?

A

Laparoscopic pyloromyotomy (aka Ramstedt’s operation) - incision is made in the smooth muscle of the pylorus to widen the canal - prognosis is excellent

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48
Q

What is acute gastritis?

A

Inflammation of the stomach presenting with nausea and vomiting

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49
Q

What is enteritis?

A

Inflammation of the intestines and presents with diarrhoea

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50
Q

What is gastroenteritis?

A

Inflammation from the stomach to the intestines, presents with nausea, vomiting and diarrhoea

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51
Q

What is the most common cause of gastroenteritis in children?

A

Viral (easily spread)

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52
Q

Where to treat patients with viral gastroenteritis?

A

Isolated room

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53
Q

What is the main concern with gastroenteritis?

A

Dehydration - are they able to keep themselves hydrated / do they need admission for IV fluids

Abx are generally not required

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54
Q

What is steatorrhoea?

A

Greasy stool with excessive fat content (suggest pancreatic insufficiency e.g. cystic fibrosis)

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55
Q

What key conditions should be thought about in loose stools?

A

Infection (gastroenteritis)

IBD

Lactose intolerance

Coeliac disease

Cystic fibrosis

Toddler’s diarrhoea

IBS

Medications (e.g. antibiotics)

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56
Q

What are some common causes of viral gastroenteritis?

A

Rotavirus

Norovirus

Adenovirus (presents with more subacute diarrhoea)

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57
Q

What is Escherichia Coli?

A

Normal intestinal bacteria - certain strains cause gastroenteritis - spread through contact with infected faeces, unwashed salads or contaminated water

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58
Q

What does E.Coli produce?

A

Shiga toxin which causes abdo cramps, bloody diarrhoea and vomiting - destroys red blood cells and leads to haemolytic uraemic syndrome

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59
Q

What should be avoided if E.coli gastroenteritis is considered?

A

Antibiotics

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60
Q

What is a common cause of travellers diarhorrea?

A

Campylobacter jejuni

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61
Q

What does campylobacter mean?

A

“Curved bacteria”

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62
Q

What type of bacteria is campylobacter?

A

Gram negative with curved or spiral shape

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63
Q

How is campylobacter spread?

A

Raw / improperly cooked poultry

Untreated water

Unpasteurised milk

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64
Q

How long is the incubation of campylobacter?

A

2-5 days

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65
Q

How long for symptoms of campylobacter to resolve?

A

3 to 6 days

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66
Q

What are the symptoms of campylobacter?

A
  • Abdo cramps
  • Diarrhoea often with blood
  • Vomiting
  • Fever
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67
Q

When are antibiotics considered for campylobacter? What are some typical choices?

A

Severe symptoms / other risks e.g. HIV or heart failure

azithromycin or ciprofloxacin

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68
Q

What is shigella spread by?

A

Faeces contaminated drinking water, swimming pools and food

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69
Q

What is the incubation period for shigella?

How long till symptoms resolve?

A

1 to 2 days

Resolve in 1 week without treatment

70
Q

What are the features of shigella?

A

Blood diarhoea, abdo cramps and fever

71
Q

What can shigella lead to?

A

The shiga toxin causes haemolytic uraemic syndrome

72
Q

What is the treatment of severe shigella cases?

A

Azithromycin or ciprofloxacin

73
Q

How is salmonella spread?

A

Eating raw eggs or poultry or food contaminated with the infected faeces of small animals

74
Q

What is the incubation period of salmonella?

How long do symptoms take to resolve?

A

Incubation is 12 hours to 3 days

Symptoms resolve within 1 week

75
Q

What are the symptoms of salmonella?

A

Watery diarrhoea which can be associated with mucus / blood

Abdo pain

Vomiting

76
Q

When are antibiotics used in salmonella?

A

Severe cases and guided by stool culture and sensitivities

77
Q

What is bacillus cereus?

A

Gram positive rod spread through inadequately cooked foods

78
Q

What is the typical food in bacillus cereus?

A

Fried rice left out at room temperature

79
Q

What toxin does bacillus cereus produce on the food?

A

Cereulide

80
Q

What does cereulide cause?

A

Abdo cramping and vomiting within 5 hours of ingestion

81
Q

When does watery diarrhoea occur in bacillus cereus infection?

A
82
Q

What types of bacteria is yersinia enterocolitica?

A

Gram negative bacillus

83
Q

What are the carriers of yersinia?

A

Pigs (eating raw / undercooked pork can cause infection)

84
Q

Who does yersinia normally affect?

A

Children with watery / bloody diarrhoea

85
Q

What are the features of yersinia?

A

Lymphadenopathy

Fever

Abdo pain

86
Q

How long is the incubation of yersinia?

How long for symptoms of yersinia to resolve?

A

4 to 7 days, illness can last longer than other casues of enteritis with symptoms lasting 3 weeks or more

87
Q

Why does yersinia sometimes get mistaken for appendicitis?

A

Older children or adults present with right sided abdominal pain due to mesenteric lymphadenitis (inflammation of the intestinal lymph nodes) and fever

88
Q

When are antibiotics needed for yersinia?

A

Severe cases and guided by stool cultures and sensitivities

89
Q

How can staph aureus cause diarrhoea?

A

Produces enterotoxins when growing on foods such as eggs, dairy and meat when eaten these cause small intestine inflammation

90
Q

What are the symptoms of infection with enterotoxin?

A

Diarrhoea

Perfuse vomiting

Abdo cramps

Fever

91
Q

When does infection with enterotoxin show and then resolve?

A

Within hours of ingestion and settle within 12 to 24 hours

92
Q

What is giardia lamblia?

A

Type of microscopic parasite living in the small intestines of mammals (pets, farmyard animals or humans)

93
Q

How is giardia lamblia spread?

A

Cysts are released in the stools of infected mammals (these contminate food / water) and are eaten

94
Q

How does giardiasis present?

A

No symptoms or chronic diarrhoea - diagnosis is made by stool microscopy

95
Q

What is the treatment of giardiasis?

A

Metronidazole

96
Q

How id gastroenteritis prevented?

A

Good hygiene

97
Q

How to care for patients in hospital with gastroenteritis?

A

Barrier nursing and rigorous infection control

98
Q

How long should children with gastroenteritis stay off of school?

A

48 hours after the symptoms have completely resolved

99
Q

How can a causative organism for gastroenteritis be found?

A

Microscopy, culture and sensitivities

100
Q

What is the general management of gastroenteritis?

A

Keep hydrated with fluid challenge (policy varies with hospital)

Recording a small volume of fluid given orally every 5-10 minutes (if they can tolerate this then they can be managed at home)

Dioralyte (rehydration solution) can be used if tolerated

Dehydrated children / those which fail the fluid challenge may require IV fluids

Give dry foods e.g. toast

Antidiarrhoeals/antiemetics are generally not recommended (loperamide / metoclopramide)

Antidiarrhoeals are particularly not used in E.Coli 0157 and shigella infections and where there is bloody diarrhoea/ high fever

Abx only used in patients at risk of complications

101
Q

Name some post gastroenteritis complications?

A

Lactose intolerance

IBS

Reactive arthritis

Guillain-Barre syndrome

102
Q

What is coeliac’s disease?

A

Autoimmune condition where explosure to gluten causes an immune reaction which creates inflammation in the small intestines

103
Q

When does coeliacs disease usually develop?

A

Early childhood (can start at any age)

104
Q

Where do the autoantibodies target in coeliacs?

A

Epithelial cells of the intestine

105
Q

Name the 2 antibodies in coeliacs?

A

Anti-tissue transglutaminase (anti-TTG)

Anti-endomysial (anti EMA)

106
Q

Do the antibody levels change in coeliacs?

A

Correlate with disease activity and rise with more active diease (may disappear with effective treatment)

107
Q

Which part of the bowel is particularly affected in coeliacs?

A

Jejunum causing atrophy of the intestinal villi

108
Q

What does coeliacs lead to?

A

Malabsorption of nutrients and disease related symptoms

109
Q

How does coeliacs present?

A

Often asymptomatic (so have a low threshold for testing)

Failure to thrive in young children

Diarrhoea

Fatigue

Weight loss

Mouth ulcers

Anaemia seconds to iron, B12 or folate deficiency

Dermatitis herpetiformis which is an itchy blistering skin rash that typically appears on the abdomen

110
Q

What neurological symptoms can coeliacs present with?

A

Peripheral neuropathy

Cerebella ataxia

Epilepsy

111
Q

What disease is strongly linked with coeliacs?

A

Type 1 diabetes (all patients with a new diagnosis are tested for coeliacs)

112
Q

What are the genetic associations with coeliacs?

A

HLA-DQ2 gene (90%)

HLA-DQ8 gene

113
Q

What auto-antibodies are associated with coeliacs?

A

Tissue transglutaminase antibodies (anti-TTG)

Endomysial antibodies (EMAs)

Deaminated gliadin peptides antibodies (anti-DGPs)

114
Q

How to diagnose coeliacs?

A

Investigate whilst patient remains on a diet containing gluten

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
115
Q

What do endoscopy and intestinal biopsy show for coeliacs?

A

Crypt hypertrophy

Villous atrophy

116
Q

What are the associations with coeliacs disease?

A

Type 1 diabetes

Thyroid disease

Autoimmune hepatitis

Primary biliary cirrhosis

Primary sclerosing cholangitis

Down’s syndrome

117
Q

What are the complications of untreated coeliacs disease?

A

Vitamin deficiency

Anaemia

Osteoporosis

Ulcerative jejunitis

Enteropathy-associated T-cell lymphoma (EATL) of the intestine

Non-Hodgkin lymphoma (NHL)

Small bowel adenocarcinoma (rare)

118
Q

What is the treatment of coeliacs?

A

Lifelong gluten free diet is essentially curative (checking coeliac antibodies can be helpful in monitoring of the disease)

119
Q

What is inflammatory bowel disease?

A

Ulterative colitis and Crohn’s disease (causes inflammation of the GI tract)

120
Q

What is the disease course of IBD?

A

Periods of remission and exacerbation

121
Q

What features are unique to Crohn’s?

A

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)

122
Q

What is associated with Crohn’s?

A

Weight loss

Strictures

Fistulas

123
Q

What are the features unique to UC?

A

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

124
Q

How does IBD present?

A

IBD should be suspected in children and teenagers presenting with perfuse diarrhoea, abdo pain, bleeding, weight loss or anaemia

During flares = fevers, malaise and dehydration

125
Q

What are some extra-intestinal manifestations of IBD?

A

Finger clubbing

Erythema nodosum

Pyoderma gangrenosum

Episcleritis and iritis

Inflammatory arthritis

Primary sclerosing cholangitis (ulcerative colitis)

126
Q

What is the testing for IBD?

A

Faecal calprotectin (released by intestines when inflammed - useful screening tool)

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 e.g. fistulas, abscesses and strictures

(Blood tests for anaemia, thyroid, kidney and liver function - raised CRP indicates active inflammation)

127
Q

What is the general management of IBD?

A

Referral to secondary care for assessment

Managed by multi-disciplinary team (paediatricians, specialist nurses, pharmacists, dieticians and surgeons)

Monitoring of growth and pubertal development (particularly when flaring or on steroids)

Inducing remission during flares and then maintaining

128
Q

How to induce remission in Crohn’s?

A

Steroids (oral prednisolone or IV hydrocortisone)

If steroids alone dont work then add immunosuppressants:

Azathioprine

Mercaptopurine

Methotrexate

Infliximab

Adalimumab

129
Q

How to maintain remission in Crohn’s?

A

First line:

  • Azathioprine
  • Mercaptopurine

Alternatives:

  • Methotrexate
  • Infliximab
  • Adalimumab
130
Q

When is surgery considered in Crohn’s?

A

Disease only affects the distal ileum (possible to resect this area to prevent further flares)

Treat strictures and fistulas

131
Q

How to induce remission in UC?

A

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

132
Q

How to maintain remission in UC?

A

Aminosalicylate (e.g. mesalazine oral or rectal)

Azathioprine

Mercaptopurine

133
Q

When is surgery used for treatment of ulcerative colitis?

A

Panproctocolectomy (removing colon and rectum as UC only usually affects here)

Patient is left with ileostomy or

ileo-anal anastomosis (j-pouch) = ileum is folded back on itself and fashioned into a larger pouch like a rectum which is then attached to the anus

134
Q

What is bilary atresia?

A

Congenital condition where a section of the bile duct is narrowed or absent resulting in cholestasis

135
Q

What else is trapped due to biliary atresia?

A

Conjugated bilirubin

136
Q

When does biliary atresia present?

A

Shortly after birth with significant jaundice due to high conjugated bilirubin levels (more than 14 days in term babies and 21 days in premature babies)

137
Q

What is the initial investigation for possible biliar atresia?

A

Conjugated and unconjugated bilirubin - high proportion of conjugated bilirubin suggests the liver is processing the bilirubin for excretion by conjugating it - but not able to excrete

138
Q

What are the majority of the causes of jaundice in the neonate?

A

Benign e.g. breast milk jaundice

139
Q

What is the management of biliary atresia?

A

Sugery - Kasai portoenterostomy - a section of the small intesting is attached to the opening of the liver where bile duct normally attaches

Full liver transplant

140
Q

What is absolute constipation?

A

Patient is unable to pass stools or wind

141
Q

What are some causes of intestinal obstruction?

A

Meconium ileus

Hirschsprung’s disease

Oesophageal atresia

Duodenal atresia

Intussusception

Imperforate anus

Malrotation of the intestines with a volvulus

Strangulated hernia

142
Q

How does intestinal obstruction present?

A

Persistant vomiting (bilious = bright green bile)

Abdo pain and distention

Failure to pass stools or wind

High pitched / tinking bowel sounds early in the obstruction and absent later

143
Q

What is the investigation for intestinal obstruction?

A

Abdo x-ray showing dilated loops of bowel proximal to the obstruction and collapsed loops of bowel distal to the obstruction

Absence of air in the rectum

144
Q

How are patient with intestinal obstruction managed?

A

Reffered to paediatric surgical unit as an emergency with inital mangement of nil by mouth and inserting a NG tube to drain the stomach

IV fluids to correct dehydration / electrolyte imbalances

145
Q

What is Hirschsprung’s disease?

A

Congenital condition where nerve cells of the myenteric plexus are absent in the distal bowel and rectum

146
Q

What is the myenteric plexus?

A

Forms the enteric nervous system - brain of the gut aka Auerbach’s plexus

147
Q

What is the myenteric plexus made up of?

A

Web of neurons, ganglion cells, receptors, synapses and neurotransmitters - responsible for stimulating peristalsis of the large bowel

148
Q

What is the key pathophysiology in Hirschsprung’s disease?

A

Absence of parasympathetic ganglion cells (during development these cells start higher in the GI tract and gradually migrate down to the distal colon and rectum - here they dont travel all the way down)

149
Q

What is it called when the entire colon is affected by Hirschsprungs disease?

A

Total colonic aganglionosis the aganglionic section of the colon doesnt relax causing it to become constricted causing loss of movement of faeces

150
Q

What is associated with Hirschisprungs?

A

Downs syndrome

Neurofibromatosis

Waardenburg syndrome (genetic condition causing pale blue eyes, hearing loss and patches of white skin and hair)

Multiple endocrine neoplasia type II

Family hx of Hirschsprung’s

151
Q

How does Hirschsprung’s disease present?

A

Delay in passing meconium (more than 24 hours)

Chronic constipation since birth

Abdo pain and distention

Vomiting

Poor weight gain and failure to thrive

Can be gradul / acute presentation

152
Q

What is Hirschsprung associated enterocolitis?

A

Inflammation and obstruction of intestine (occuring in 20% of neonates with Hirschsprung’s disease) typically presents within 2-4 weeks of birth with fever, abdo distention, diarrhoea (often with blood) and features of sepsis

153
Q

Why is HAEC worrying and how is it treated?

A

Life threatening - leads to toxic megacolon and perforation of bowel

Treated with abx, fluid reuscitation and decompression of the obstructed bowel

154
Q

What is the management of Hirschsprung’s?

A

Abdo x-ray for diagnosing intestinal obstruction and demonstrating features of HAEC

Rectal biopsy to confirm the diagnosis (histology will demonstate an absence of ganglionic cells)

Fluid resuscitation and management of intestinal obstruction

IV abx in HAEC

155
Q

What is the definitive management of Hirschsprung’s?

A

Surgical removal of aganglionic cells - most have a normal life after surgery but may be some degree of incontinence

156
Q

What is intussusception?

A

Condition where bowel ‘invaginates’ or ‘telescopes’ into itself

157
Q

What conditions are associated with intussusception?

A

Concurrent viral illness

Henoch-Schonlein purpura

Cystic fibrosis

Intestinal polyps

Meckel diverticulum

158
Q

How does intusseception present?

A
  • Severe colicy abdo pain
  • Pale, lethargic and unwell child
  • “Redcurrant jelly stool”
  • Right upper quadrant mass (sausage shaped)
  • Vomiting
  • Intestinal obstruction
159
Q

How is intussusception diagnosed?

A

Ultrasound scan or contrast enema

160
Q

How is intussuception managed?

A

Therapeutic enemas (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 (if enemas don’t work or if bowel becomes gangrenous/perforates)

161
Q

What are some complications due to intussuception?

A

Obstruction

Gangrenous bowel

Perforation

Death

162
Q

What is appendicitis?

A

Inflammation of the appendix (a small thin tube sprouting from the caecum) - becomes inflammed due to infection being trapped there by obstruction at the point where the appendix meets the bowel

163
Q

What can appendicitis quickly lead to?

A

Gangrene and rupture causing peritonitis

164
Q

When is the peak incidence of appendicitis?

A

Patients aged 10-20

165
Q

What are the features of appendicitis?

A

Abdo pain which migrates from centre to RIF

Tenderness at Mc Burney’s point localised area one third from ASIS to umbilicus

Anorexia (loss of appetite)

N&V

Rovsing’s sign (palpation on LIF causes pain in RIF)

Guarding on abdo palpation

Rebound tenderness on RIF

Percussion tenderness which is pain and tenderness when percussing the abdomen

166
Q

What do rebound tendernes and percussion tenderness suggest in appendicitis?

A

Peritonitis caused by ruptured appendix

167
Q

How is appendicitis diagnosed?

A

Clinical presentation and raised inflammatory markers

CT scan can be used to confirm the diagnosis - particularly when another diagnosis is more likely

Ultrasound in female to exclude ovarian and gynae pathology

168
Q

What to do if a patient has clinical presentation suggestive of appendicitis but investigations are negative, what is the next step?

A

Diagnostic laparoscopy to visualise appendix - can then proceed to an appendicectomy during same procedure

169
Q

What are the key differentials to appendicitis?

A

Ectopic pregnancy (take a serum / urine bHCG)

Ovarian cysts (particularly with rupture / torsion)

Meckel’s diverticulum (malformation of distal ileum in 2 % of population, usually asymptomatic but can bleed, become inflammed, rupture or cause a volvulus / intussusception) - often removed prophylactically if itendified incidentally during other bado operations

Mesenteric adenitis (inflammed abdo lymph nodes causing abdo pain in younger children associated with tonsillitis or URTI - not specific treatment required)

Appendix mass - when omentum surrounds and sticks to the inflammed appendix, forming a mass in the RIF - managed conservatively with supportive treatment and abx followed by appendicectomy once condition has resolved

170
Q

What is the management of appendicitis?

A

Emergency admission to hospital (older children can be managed by adult general surgical teams >10)

Appendicectomy

Laparoscopic sugery = fewer risks and faster recovery compared to open sugery (laparotomy)

171
Q

What are some complications of appendicectomy?

A

Bleeding, infection, pain and scars

Damage to bowel, bladder or other organs

Removal of a normal appendix

Anaesthetic risks

Venous thromboembolism

Paediatrics (18 decks)

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