Paediatrics Gastroenterology Flashcards
What are the causes of abdo pain in children?
Non-organic or functional (most common in children over 5)
Medical
Surgical
What are some medical causes of abdo pain?
Constipation is very common
UTI
Coeliac disease
IBD
IBS
Mesenteric adenitis
Adbominal migraine
Pyelonephritis
Henoch-Schonlein purpura
Tonsilitis
Diabetic ketoacidosis
Infantile colic
What are the additional causes of abdo pain in adolescent girls?
Dysmenorrhoea (period pain)
Mittelschmerz (ovulation pain)
Ectopic pregnancy
Pelvic inflammatory disease
Ovarian torsion
Pregnancy
What are some surgical causes of abdominal pain?
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
Name some 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
Abdo tenderness
What initial investigations for abdo pain in children?
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
How is recurrent abdo pain diagnosed in children?
Repeated episodes of abdo pain without an identifiable underlying cause (pain is non-organic or functional)
What is the result of recurrent abdo pain?
Missed days at school and parental anxiety
What abdo diagnoses overlap?
Recurrent abdo pain
Abdo migraine
IBS
Functional abdo pain
What often causes recurrent abdo pain?
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
What is the management of recurrant abdo pain?
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
What is an abdominal migraine?
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
What is associated with an abdominal migraine?
- Nausea and vomiting
- Anorexia
- Pallor
- Headache
- Photophobia
- Aura
What is the general management of abdominal migraine?
Similar to adults - careful explanation and education is important
Treating acute attacks
Preventative measures
How to treat the acute attacks in abdominal migraine?
Low stimulus environment (quiet, dark room)
Paracetamol
Ibuprofen
Sumatriptan
What are some preventative medications against abdominal migraines?
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
What are most cases of constipation caused by?
Idiopathic or functional (not a significant cause other than lifestyle factors)
How often may breast fed babies open their bowels?
As little as once a week (this is normal)
What are the typical features which suggest constipation?
- 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
What is encopresis?
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
What are some rarer causes of encopresis?
- Spina bifida
- Hirschprung’s disease
- Cerebral palsy
- Learning disability
- Psychosocial stress
- Abuse
What lifestyle factors can cause constipation?
- 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)
What causes desensitisation of the rectum?
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
What are some secondary causes of constipation?
Hirschsprung’s disease
Cystic fibrosis (particularly meconium ileus)
Hypothyroidism
Spinal cord lesions
Sexual abuse
Intestinal obstruction
Anal stenosis
Cows milk intolerance
What are the red flags for constipation?
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)
What are some complciations of constipation in children?
Pain
Reduced sensation
Anal fissures
Haemorrhoids
Overflow and soiling
Psychosocial morbidity
When can a diagnosis of idiopathic constipation be made?
Without investigations, provided red flags are considered
How to manage constipation in children?
- 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
What is gastro-oesophageal reflux?
Contents from stomach reflux through the lower oesophageal sphincter
Why do babies have more reflux?
Immaturity of the lower oesophageal sphincter (90% of infants stop having reflux by 1 year)
What are some signs of problematic reflux?
- Chronic cough
- Hoarse cry
- Distress, crying or unsettled after feeding
- Reluctance to feed
- Pneumonia
- Poor weight gain
What are the symptoms of GORD in children over 1 year?
Similar to adults with heartburn, acid regurgitation, retrosternal or epigastric pain, bloating and nocturnal cough
What are the causes of vomiting?
Overfeeding
Gastro-oesophageal reflux
Pyloric stenosis (projective vomiting)
Gastritis or gastroenteritis
Appendicitis
Infections such as UTI, tonsillitis or meningitis
Intestinal obstruction
Bulimia
What are some red flags for reflux?
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
What is the management for simple cases of reflux?
- Small, frequent meals
- Burping regularly to help milk settle
- Not over-feeding
- Keeping baby upright after feeding (i.e. not lying flat)
What do more problematic cases of GORD get treated with?
Gaviscon mixed with feeds
Thickened milk or formula (specific anti-reflux formulas are available)
Omeprazole where ranitidine is inadequate (not ranitidine as its banned)
What further investigation is there for GORD?
Barium meal and endoscopy
What is the treatment for severe GORD?
Surgical fundoplication
What is Sandifer’s syndrome?
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
What are the differentials of Sandifer’s syndrome?
Infantile spasms (West syndrome) and seizures
What is the pyloric sphincter?
Ring of smooth muscle between stomach and duodenum?
What is pyloric stenosis?
Hypertrophy (thickening) of the pylorus
What does pyloric stenosis typically cause?
Projectile vomiting (due to increasing power peristalsis of the stomach as it tries to push food into the duodenum)
What are the features of pyloric stenosis?
- 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
What will blood gas analysis show for pyloric stenosis?
Hypochloric (low cholride) metabolic alkalosis as the baby is vomiting the hydrochloric acid from the stomach
How is pyloric stenosis diagnosed?
Abdominal ultrasound to visualise the thickened pylorus
What is the treatment of pyloric stenosis?
Laparoscopic pyloromyotomy (aka Ramstedt’s operation) - incision is made in the smooth muscle of the pylorus to widen the canal - prognosis is excellent
What is acute gastritis?
Inflammation of the stomach presenting with nausea and vomiting
What is enteritis?
Inflammation of the intestines and presents with diarrhoea
What is gastroenteritis?
Inflammation from the stomach to the intestines, presents with nausea, vomiting and diarrhoea
What is the most common cause of gastroenteritis in children?
Viral (easily spread)
Where to treat patients with viral gastroenteritis?
Isolated room
What is the main concern with gastroenteritis?
Dehydration - are they able to keep themselves hydrated / do they need admission for IV fluids
Abx are generally not required
What is steatorrhoea?
Greasy stool with excessive fat content (suggest pancreatic insufficiency e.g. cystic fibrosis)
What key conditions should be thought about in loose stools?
Infection (gastroenteritis)
IBD
Lactose intolerance
Coeliac disease
Cystic fibrosis
Toddler’s diarrhoea
IBS
Medications (e.g. antibiotics)
What are some common causes of viral gastroenteritis?
Rotavirus
Norovirus
Adenovirus (presents with more subacute diarrhoea)
What is Escherichia Coli?
Normal intestinal bacteria - certain strains cause gastroenteritis - spread through contact with infected faeces, unwashed salads or contaminated water
What does E.Coli produce?
Shiga toxin which causes abdo cramps, bloody diarrhoea and vomiting - destroys red blood cells and leads to haemolytic uraemic syndrome
What should be avoided if E.coli gastroenteritis is considered?
Antibiotics
What is a common cause of travellers diarhorrea?
Campylobacter jejuni
What does campylobacter mean?
“Curved bacteria”
What type of bacteria is campylobacter?
Gram negative with curved or spiral shape
How is campylobacter spread?
Raw / improperly cooked poultry
Untreated water
Unpasteurised milk
How long is the incubation of campylobacter?
2-5 days
How long for symptoms of campylobacter to resolve?
3 to 6 days
What are the symptoms of campylobacter?
- Abdo cramps
- Diarrhoea often with blood
- Vomiting
- Fever
When are antibiotics considered for campylobacter? What are some typical choices?
Severe symptoms / other risks e.g. HIV or heart failure
azithromycin or ciprofloxacin
What is shigella spread by?
Faeces contaminated drinking water, swimming pools and food
What is the incubation period for shigella?
How long till symptoms resolve?
1 to 2 days
Resolve in 1 week without treatment
What are the features of shigella?
Blood diarhoea, abdo cramps and fever
What can shigella lead to?
The shiga toxin causes haemolytic uraemic syndrome
What is the treatment of severe shigella cases?
Azithromycin or ciprofloxacin
How is salmonella spread?
Eating raw eggs or poultry or food contaminated with the infected faeces of small animals
What is the incubation period of salmonella?
How long do symptoms take to resolve?
Incubation is 12 hours to 3 days
Symptoms resolve within 1 week
What are the symptoms of salmonella?
Watery diarrhoea which can be associated with mucus / blood
Abdo pain
Vomiting
When are antibiotics used in salmonella?
Severe cases and guided by stool culture and sensitivities
What is bacillus cereus?
Gram positive rod spread through inadequately cooked foods
What is the typical food in bacillus cereus?
Fried rice left out at room temperature
What toxin does bacillus cereus produce on the food?
Cereulide
What does cereulide cause?
Abdo cramping and vomiting within 5 hours of ingestion
When does watery diarrhoea occur in bacillus cereus infection?
What types of bacteria is yersinia enterocolitica?
Gram negative bacillus
What are the carriers of yersinia?
Pigs (eating raw / undercooked pork can cause infection)
Who does yersinia normally affect?
Children with watery / bloody diarrhoea
What are the features of yersinia?
Lymphadenopathy
Fever
Abdo pain
How long is the incubation of yersinia?
How long for symptoms of yersinia to resolve?
4 to 7 days, illness can last longer than other casues of enteritis with symptoms lasting 3 weeks or more
Why does yersinia sometimes get mistaken for appendicitis?
Older children or adults present with right sided abdominal pain due to mesenteric lymphadenitis (inflammation of the intestinal lymph nodes) and fever
When are antibiotics needed for yersinia?
Severe cases and guided by stool cultures and sensitivities
How can staph aureus cause diarrhoea?
Produces enterotoxins when growing on foods such as eggs, dairy and meat when eaten these cause small intestine inflammation
What are the symptoms of infection with enterotoxin?
Diarrhoea
Perfuse vomiting
Abdo cramps
Fever
When does infection with enterotoxin show and then resolve?
Within hours of ingestion and settle within 12 to 24 hours
What is giardia lamblia?
Type of microscopic parasite living in the small intestines of mammals (pets, farmyard animals or humans)
How is giardia lamblia spread?
Cysts are released in the stools of infected mammals (these contminate food / water) and are eaten
How does giardiasis present?
No symptoms or chronic diarrhoea - diagnosis is made by stool microscopy
What is the treatment of giardiasis?
Metronidazole
How id gastroenteritis prevented?
Good hygiene
How to care for patients in hospital with gastroenteritis?
Barrier nursing and rigorous infection control
How long should children with gastroenteritis stay off of school?
48 hours after the symptoms have completely resolved
How can a causative organism for gastroenteritis be found?
Microscopy, culture and sensitivities
What is the general management of gastroenteritis?
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
Name some post gastroenteritis complications?
Lactose intolerance
IBS
Reactive arthritis
Guillain-Barre syndrome
What is coeliac’s disease?
Autoimmune condition where explosure to gluten causes an immune reaction which creates inflammation in the small intestines
When does coeliacs disease usually develop?
Early childhood (can start at any age)
Where do the autoantibodies target in coeliacs?
Epithelial cells of the intestine
Name the 2 antibodies in coeliacs?
Anti-tissue transglutaminase (anti-TTG)
Anti-endomysial (anti EMA)
Do the antibody levels change in coeliacs?
Correlate with disease activity and rise with more active diease (may disappear with effective treatment)
Which part of the bowel is particularly affected in coeliacs?
Jejunum causing atrophy of the intestinal villi
What does coeliacs lead to?
Malabsorption of nutrients and disease related symptoms
How does coeliacs present?
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
What neurological symptoms can coeliacs present with?
Peripheral neuropathy
Cerebella ataxia
Epilepsy
What disease is strongly linked with coeliacs?
Type 1 diabetes (all patients with a new diagnosis are tested for coeliacs)
What are the genetic associations with coeliacs?
HLA-DQ2 gene (90%)
HLA-DQ8 gene
What auto-antibodies are associated with coeliacs?
Tissue transglutaminase antibodies (anti-TTG)
Endomysial antibodies (EMAs)
Deaminated gliadin peptides antibodies (anti-DGPs)
How to diagnose coeliacs?
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
What do endoscopy and intestinal biopsy show for coeliacs?
Crypt hypertrophy
Villous atrophy
What are the associations with coeliacs disease?
Type 1 diabetes
Thyroid disease
Autoimmune hepatitis
Primary biliary cirrhosis
Primary sclerosing cholangitis
Down’s syndrome
What are the complications of untreated coeliacs disease?
Vitamin deficiency
Anaemia
Osteoporosis
Ulcerative jejunitis
Enteropathy-associated T-cell lymphoma (EATL) of the intestine
Non-Hodgkin lymphoma (NHL)
Small bowel adenocarcinoma (rare)
What is the treatment of coeliacs?
Lifelong gluten free diet is essentially curative (checking coeliac antibodies can be helpful in monitoring of the disease)
What is inflammatory bowel disease?
Ulterative colitis and Crohn’s disease (causes inflammation of the GI tract)
What is the disease course of IBD?
Periods of remission and exacerbation
What features are unique to Crohn’s?
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)
What is associated with Crohn’s?
Weight loss
Strictures
Fistulas
What are the features unique to UC?
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
How does IBD present?
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
What are some extra-intestinal manifestations of IBD?
Finger clubbing
Erythema nodosum
Pyoderma gangrenosum
Episcleritis and iritis
Inflammatory arthritis
Primary sclerosing cholangitis (ulcerative colitis)
What is the testing for IBD?
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)
What is the general management of IBD?
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
How to induce remission in Crohn’s?
Steroids (oral prednisolone or IV hydrocortisone)
If steroids alone dont work then add immunosuppressants:
Azathioprine
Mercaptopurine
Methotrexate
Infliximab
Adalimumab
How to maintain remission in Crohn’s?
First line:
- Azathioprine
- Mercaptopurine
Alternatives:
- Methotrexate
- Infliximab
- Adalimumab
When is surgery considered in Crohn’s?
Disease only affects the distal ileum (possible to resect this area to prevent further flares)
Treat strictures and fistulas
How to induce remission in UC?
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
How to maintain remission in UC?
Aminosalicylate (e.g. mesalazine oral or rectal)
Azathioprine
Mercaptopurine
When is surgery used for treatment of ulcerative colitis?
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
What is bilary atresia?
Congenital condition where a section of the bile duct is narrowed or absent resulting in cholestasis
What else is trapped due to biliary atresia?
Conjugated bilirubin
When does biliary atresia present?
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)
What is the initial investigation for possible biliar atresia?
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
What are the majority of the causes of jaundice in the neonate?
Benign e.g. breast milk jaundice
What is the management of biliary atresia?
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
What is absolute constipation?
Patient is unable to pass stools or wind
What are some causes of intestinal obstruction?
Meconium ileus
Hirschsprung’s disease
Oesophageal atresia
Duodenal atresia
Intussusception
Imperforate anus
Malrotation of the intestines with a volvulus
Strangulated hernia
How does intestinal obstruction present?
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
What is the investigation for intestinal obstruction?
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
How are patient with intestinal obstruction managed?
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
What is Hirschsprung’s disease?
Congenital condition where nerve cells of the myenteric plexus are absent in the distal bowel and rectum
What is the myenteric plexus?
Forms the enteric nervous system - brain of the gut aka Auerbach’s plexus
What is the myenteric plexus made up of?
Web of neurons, ganglion cells, receptors, synapses and neurotransmitters - responsible for stimulating peristalsis of the large bowel
What is the key pathophysiology in Hirschsprung’s disease?
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)
What is it called when the entire colon is affected by Hirschsprungs disease?
Total colonic aganglionosis the aganglionic section of the colon doesnt relax causing it to become constricted causing loss of movement of faeces
What is associated with Hirschisprungs?
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
How does Hirschsprung’s disease present?
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
What is Hirschsprung associated enterocolitis?
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
Why is HAEC worrying and how is it treated?
Life threatening - leads to toxic megacolon and perforation of bowel
Treated with abx, fluid reuscitation and decompression of the obstructed bowel
What is the management of Hirschsprung’s?
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
What is the definitive management of Hirschsprung’s?
Surgical removal of aganglionic cells - most have a normal life after surgery but may be some degree of incontinence
What is intussusception?
Condition where bowel ‘invaginates’ or ‘telescopes’ into itself
What conditions are associated with intussusception?
Concurrent viral illness
Henoch-Schonlein purpura
Cystic fibrosis
Intestinal polyps
Meckel diverticulum
How does intusseception present?
- Severe colicy abdo pain
- Pale, lethargic and unwell child
- “Redcurrant jelly stool”
- Right upper quadrant mass (sausage shaped)
- Vomiting
- Intestinal obstruction
How is intussusception diagnosed?
Ultrasound scan or contrast enema
How is intussuception managed?
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)
What are some complications due to intussuception?
Obstruction
Gangrenous bowel
Perforation
Death
What is appendicitis?
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
What can appendicitis quickly lead to?
Gangrene and rupture causing peritonitis
When is the peak incidence of appendicitis?
Patients aged 10-20
What are the features of appendicitis?
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
What do rebound tendernes and percussion tenderness suggest in appendicitis?
Peritonitis caused by ruptured appendix
How is appendicitis diagnosed?
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
What to do if a patient has clinical presentation suggestive of appendicitis but investigations are negative, what is the next step?
Diagnostic laparoscopy to visualise appendix - can then proceed to an appendicectomy during same procedure
What are the key differentials to appendicitis?
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
What is the management of appendicitis?
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)
What are some complications of appendicectomy?
Bleeding, infection, pain and scars
Damage to bowel, bladder or other organs
Removal of a normal appendix
Anaesthetic risks
Venous thromboembolism
