Paeds: Gastro Flashcards
Intussusception
what is it
bowel invaginates or telescopes into itself
palpable mass in the abdo and obstruction to the passage of faeces through the bowel
Intussusception
epidemiology
6m - 2y
more common in boys
Intussusception
associated conditions
- concurrent VIRAL ILLNESS
- Henoch-Schonlein purpura
- cystic fibrosis
- intestinal polyps
- Meckel diverticulum
Intussusception
presentation
- REDCURRANT JELLY STOOL
- SAUSAGE SHAPED mass in RUQ on palpation
- severe, colicky abdo pain
- pale, lethargic + unwell child
- vomiting
- intestinal obstruction
- URTI preceding the illness
Intussusception
initial inx
US
Intussusception
mnx
- therapeutic enemas: contrast, water or air are pumped into the colon to force the folded bowel out
- 2nd line: surgical reduction if bowel becomes gangrenous or perforated
Intussusception
complications
- obstruction
- gangrenous bowel
- perforation
- death
Biliary atresia
what is it
congenital condition where a section of the bile duct is narrowed or absent
results in cholestasis: bile cannot be transported from liver to bowel
conjugated bilirubin cannot be excreted
Biliary atresia
presentation
- shortly after birth
- persistent jaundice >14d
Biliary atresia
initial inx
conjugated and unconjugated bilirubin
high conjugated = biliary atresia
Biliary atresia
mnx
surgery: the Kasai portoenterostomy
some may need a full liver transplant to resolve the condition
Biliary atresia
what is involved in the Kasai portoenterostomy
involves attaching a section of the small intestine to the opening of the liver, where the bile duct normally attaches
Pyloric Stenosis
what is the pyloric sphincter
a ring of smooth muscle that forms the canal between the stomach and the duodenum
Pyloric Stenosis
what is it
hypertrophy and therefore narrowing of the pylorus
Pyloric Stenosis
how does projectile vomiting occur
after feeding, there is increasingly powerful peristalsis in the stomach as it tries to push food into the duodenum
it ejects the food into the oesophagus out of the mouth and across the room
Pyloric Stenosis
features
- projectile vomiting
- presents in the 1st few weeks of life
- failure to thrive
- round mass felt in upper abdo that feels like a large olive
Pyloric Stenosis
what is the mass felt
hypertrophic muscle of the pylorus
Pyloric Stenosis
what will blood gas analysis show
hypochloric (low Chloride)
metabolic alkalosis
Pyloric Stenosis
dx
abdominal US to visualise thickened pylorus
Pyloric Stenosis
trx
laparoscopic pyloromyotomy aka Ramstedt’s operation
Pyloric Stenosis
what is Ramstedt’s operation?
laparoscopic pyloromyotomy
an incision is made i the smooth muscle of the pylorus to widen the canal
Gastroenteritis
what is acute gastritis
inflammation of the stomach and presents with N + V
Gastroenteritis
what is enteritis
inflammation of the intestines and presents with diarrhoea
Gastroenteritis
what is gastroenteritis
inflammation from the stomach to the intestinges and presents with N + V + diarrhoea
Gastroenteritis
the most common cause
viral : rotavirus and norovirus
Gastroenteritis
main concern
dehydration
Gastroenteritis
what does steatorrhoea mean
greasy stools with excessive fat content
suggests a problem with digesting fats e.g. pancreatic insufficiency (CF?)
Gastroenteritis
Ddx of diarrhoea in children
- infection (gastroenteritis)
- IBD
- lactose intolerance
- coeliac
- CF
- toddler’s diarrhoea
- IBS
- medications (e.g. abx)
Gastroenteritis
less common cause presenting with subacute diarrhoea
adenovirus
Gastroenteritis
how is Escherichia coli spread
through contact with infected faeces, unwashed salads or contaminated water
Gastroenteritis
pathogenesis of E.coli
E.coli 0157 produces the Shiga toxin –> abdo cramps, bloody diarrhoea + vomiting
the Shiga toxin destroys blood cells and leads to haemolytic uraemic syndrome
Gastroenteritis
why should abx be avoided if E.coli gastroenteritis is considered
they increase the risk of haemolytic uraemic syndrome
Gastroenteritis
most common cause of bacterial gastroenteritis worldwide
Campylobacter Jejuni
Gastroenteritis
common cause of travellers diarrhoea
Campylobacter Jejuni
Gastroenteritis
what does Campylobacter mean and what is it?
‘curved bacteria’
a gram -ve bacteria that has a curved or spiral shape
Gastroenteritis
how is Campylobacter spread?
- raw or improperly cooked poultry
- untreated water
- unpasteurised milk
Gastroenteritis
incubation period for Campylobacter
2-5d
Gastroenteritis
Campylobacter symptoms
- abdo cramps
- diarrhoea often with blood
- vomiting
- fever
symptoms resolve after 3-6d
Gastroenteritis
Campylobacter: when can abx be considered
after isolating the organism where pts have severe sx or other RFs (HIV or HF)
Gastroenteritis
Campylobacter abx choice
azithromycin or ciprofloaxin
Gastroenteritis
how is Shigella spread
by faeces contaminating drinking water, swimming pools + foods
Gastroenteritis
shigella: incubation period
1-2d
Gastroenteritis
shigella: when do sx resolve
within 1w
Gastroenteritis
shigella: sx
- watery diarrhoea that can be associated with mucus or blood
- abdo pain
- vomiting
Gastroenteritis
shigella: when to use abx
only in severe cases guided by stool culture and sensitivities
Gastroenteritis
Bacillus Cereus
gram positive rod
Gastroenteritis
Bacillus Cereus: how is it spread
through inadequately cooked food
it grows well on food not immediately refrigerated after cooking
typically fried rice left out at room temp
Gastroenteritis
Bacillus Cereus: how does it cause abdo cramping and vomiting
whilst growing on food it produces a toxin called cereulide
abdo cramping and V within 5hrs of ingestion
Gastroenteritis
Bacillus Cereus: how does it cause watery diarrhoea
it arrives in the intestine and produces a different toxin
> 8h after ingestion
Gastroenteritis
Bacilius Cereus: when do sx resolve
within 24h
Gastroenteritis
Yersinia Enterocolitica
gram negative bacillus
Gastroenteritis
Yersinia Enterocolitica: what can cause infection
eating raw or undercooked pork as pigs are carriers of Yersinia
also spread through contamination with the urine or faeces of other mammal such as rats and rabbits
Gastroenteritis
Yersinia Enterocolitica presentation
- most freq affects children
- water or bloody diarrhoea
- abdo pain
- fever
- LYMPADENOPATHY
can last 3w or more
Gastroenteritis
Yersinia Enterocolitica: incubation
4-7d
Gastroenteritis
Yersinia Enterocolitica: why can older children or adults present with right sided abdo pain
due to mesenteric lymphadenitis (inflammation in the intestinal lymph nodes)
can give the impression of appendicitis
Gastroenteritis
Yersinia Enterocolitica: mnx
abx are only necessary in severe cases and shold be guided by stool culture and sensitivities
Gastroenteritis
Staphylococcus Aureus produces what
enterotoxins when growing on food such as eggs, dairy and meat
Gastroenteritis
S.Areus enterotoxin causes what?
small intestine inflammation (enteritis)
Gastroenteritis
S.Aureus enterotoxin sx
- diarrhoea
- perfuse vomiting
- abdo cramps
- fever
Gastroenteritis
S.Aureus enterotoxin: sx onset
within hours of ingestion and settle within 12-24 hours
Gastroenteritis
what is Giardia lamblia
a type of microscopic parasite that lives in the small intestines of mammals
Gastroenteritis
how do Giardia lamblia infect a new host
it releases cysts in the stools of infected mammals
the cysts contaminate food or water and are eaten, infecting a new host
faecal-oral transmission
Gastroenteritis
Giardiasis sx
- many not cause any
- chronic diarrhoea
Gastroenteritis
Giardiasis dx
stool microscopy
Gastroenteritis
Giardiasis trx
metronidazole
Gastroenteritis
principles of mnx
- good hygiene
- immediately isolate to prevent spread: barrier nursing and infection control.
- establish causative organism with faecal MC+S
- Fluid challenge
Gastroenteritis
should children stay off school
yes, until 48hrs after the sx have completely resolved
Gastroenteritis
what is a fluid challenge
- record a small volume of fluid given orally every 5-10min to esnure they can tolerate
- if they can, they can be hydrated at home
Gastroenteritis
should you take medications such as loperamide and metoclopramide
no, not recommended
antidiarrheal medications are particularly avoided in e.coli 0157 and shigella infections and where there is bloody diarrhoea or high fever
Gastroenteritis
post gastroenteritis complications
- lactose intolerance
- IBS
- reactive arthritis
- Gullain-Barré syndrome
Hirschsprung’s Disease
what is it
a congenital condition where nerve cells of the myenteric plexus are absent in the distal bowel and rectum
Hirschsprung’s Disease
what is the myenteric plexus
aka Auerbach’s plexus
forms the enteric nervous system. It is the brain of the gut
runs all the way along the bowel
a complex web of neurones, ganglion cells, receptors, synapses and neurotransmitters.
responsible for stimulating peristalsis of the large bowel.
Hirschsprung’s Disease
key pathophysiology
the absence of parasympathetic ganglion cells at a section at the end of the colon
Hirschsprung’s Disease
what is total colonic aganglionosis
When the entire colon is affected, without innervation
Hirschsprung’s Disease
what causes the bowel to become distended and full
The aganglionic section of colon does not relax, causing it to becomes constricted
This leads to loss of movement of faeces and obstruction in the bowel.
so proximal to the obstruction the bowel becomes distended and full.
Hirschsprung’s Disease
what greatly increases the risk of it
a FH
Hirschsprung’s Disease
what other syndromes is it associated with (4)
- Downs syndrome
- Neurofibromatosis
- Waardenburg syndrome (a genetic condition causing pale blue eyes, hearing loss and patches of white skin and hair)
- Multiple endocrine neoplasia type II
Hirschsprung’s Disease
presentation
- acute intestinal obstruction shortly after birth if lots of bowel affected
- delay in passing meconium (24hrs)
- chronic constipation since birth
- abdo pain + distention
- vomiting
- poor weight gain and failure to thrive
what is Hirschsprung-Associated Enterocolitis (HAEC)
inflammation and obstruction of the intestine occurring in around 20% of neonates with Hirschsprung’s disease
how does Hirschsprung-Associated Enterocolitis typically present
within 2-4 weeks of birth with:
- fever
- abdominal distention
- diarrhoea (often with blood)
- features of sepsis.
life threatening and can lead to toxic megacolon and perforation of the bowel.
mnx of Hirschsprung-Associated Enterocolitis
urgent antibiotics, fluid resuscitation and decompression of the obstructed bowel.
Hirschsprung’s Disease
definitive mnx
surgical removal of the aganglionic section of bowel
Hirschsprung’s Disease
confirm dx
Rectal biopsy
histology will show an absence of ganglionic cells.
abdo xray can be helpful
GOR
why do babies suffer from it
there is immaturity of the lower oesophageal sphincter
allowing stomach contents to easily reflux into the oesophagus
it is normal and normally stops by 1 yr
GOR
signs of problematic reflux (6)
- chronic cough
- hoarse cry
- distress, crying or unsettled after feeding
- reluctance to feed
- pneumonia
- poor weight gain
GOR
how may children over 1yr present
- heartburn
- acid regurg
- epigastric pain
- bloating
- nocturnal cough
possible causes of vomiting
- overfeeding
- GOR
- pyloric stenosis
- gastritis or gastroenteritis
- appendicitis
- infections: UTI, tonsilitis, meningitis
- intestinal obstruction
- bulimia
red flags in a vomiting hx
- not keeping down any feed
- projectile
- bile stained
- haematemesis or melaena
- abdominal distention
- reduced consciousness, bulging fontanelle or neuro signs
- resp sx
- blood in stool
- signs of infection
- rash, angioedema + other signs of allergy
- apnoeas
vomiting
not keeping down any feed may suggest what
pyloric stenosis or intestinal obstruction
bile stained vomit may suggest what
intestinal obstruction
vomiting
haematemesis or malaena may suggest what
peptic ulcer, oesophagitis or varices
vomiting
resp sx may suggest what
aspiration or infection
vomiting
blood in stool may suggest what
gastroenteritis or cows milk protein allergy
vomiting
rash, angioedema and other signs of allergy may suggest what
cows milk protein allergy
GOR
what to advise parents in simple cases
- small, frequent meals
- burping regularly to help milk settle
- not over feeding
- keep baby upright after feeding
GOR
trx for more problematic cases
- Gaviscon mixed with feeds
- thickened milk or formula
- Ranitidine
- Omeprazole where ranitidine is inadequate
AXR shows double bubble. Infant billious vomiting since birth. What is it
duodenal atresia
whom are duodenal atresias more common in
Down’s
trx of duodenal atresia
Duodenoduodenostomy
Mesenteric adenitis
presentation
history of pain in the right iliac fossa, usually following an acute viral illness
Mesenteric adenitis
mnx
- exclude appendicitis
- monitored overnight to look for worsening of their clinical status
Constipation
what is idiopathic/functional constipation
not a significant underlying cause other than simple lifestyle factors.
Constipation
secondary causes
- Hirschsprung’s disease
- cystic fibrosis
- hypothyroidism
Constipation
typical features
- <3 stools/week
- Hard stools that are difficult to pass
- Rabbit dropping stools
- Straining and painful passages of stools
- Abdominal pain
- Holding an abnormal posture (retentive posturing)
- Rectal bleeding assc w/ hard stools
- Faecal impaction causing overflow soiling, with incontinence of particularly loose smelly stools
- Hard stools may be palpable in abdomen
- Loss of the sensation of the need to open the bowels
Constipation
what is the term for faecal incontinence
encopresis
Constipation
when is encopresis considered pathological
4y
Constipation
usual cause of encopresis
chronic constipation where the rectum becomes stretched and looses sensation
Large hard stools remain in the rectum and only loose stools are able to bypass the blockage and leak out, causing soiling
Constipation
rarer causes of encopresis
- Spina bifida
- Hirschprung’s disease
- Cerebral palsy
- Learning disability
- Psychosocial stress
- Abuse
Constipation
what is faecal impaction
a large, hard stool blocks the rectum
Constipation
what is desensitisation of the rectum
Often patients develop a habit of not opening their bowels when they need to and ignoring the sensation of a full rectum. Over time they loose the sensation of needing to open their bowels,
Constipation
red flags: what could not passing meconium within 48h of birth indicate
cystic fibrosis or Hirschsprung’s disease
Constipation
red flags: what could neuro signs indicate
cerebral palsy or spinal cord lesion
Constipation
red flags: what could vomiting indicate
intestinal obstruction or Hirschsprung’s disease
Constipation
red flags: what could ribbon stool indicate
anal stenosis
Constipation
red flags: what could an Abnormal anus indicate
anal stenosis, inflammatory bowel disease or sexual abuse
Constipation
red flags: what could an Abnormal lower back or buttocks indicate
spina bifida, spinal cord lesion or sacral agenesis
Constipation
red flags: what could failure to thrive indicate
coeliac disease, hypothyroidism or safeguarding
Constipation
red flags: what could acute severe abdominal pain and bloating indicate
obstruction or intussusception
Constipation
complications (6)
Pain Reduced sensation Anal fissures Haemorrhoids Overflow and soiling Psychosocial morbidity
Constipation
mnx
- Correct reversible contributing factors: high fibre diet + good hydration
- laxatives (movicol)
- Faecal impaction may require a disimpaction regimen with high doses of laxatives at first
- Encourage and praise visiting the toilet. This could involve scheduling visits, a bowel diary and star charts.
Constipation
what is first line laxatives
movicol
