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YR5 Specialties > Paeds GASTRO > Flashcards

Paeds GASTRO Flashcards

1
Q

What is the commonest cause of vomiting in infancy?

A

Gastro-oesophageal reflux

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2
Q

What is the cause of GOR in babies?

A

Inappropriate relaxation of the LOS (functional immaturity)
= a normal physiological process in infancy
Affects >40% infants

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3
Q

When does GOR present? By when does GOR usuallly resolve?

A

Usually develops before 8w
12 months: if persistent, may be due to GORD

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4
Q

How does GOR present?

A

Vomiting/ regurgitation: milky vomits after feeds
Vomiting may occur after being laid flat
Excessive crying, esp. while feeding

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5
Q

How is GOR diagnosed?

A

Clinical dx
24h LOS pH

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6
Q

What are 6 symptoms are considered red flags suggesting disorders other than GOR?

A

Projectile vomiting
Bilious vomiting
Onset after 6m/ persisting after 1y
Abdo distension/ mass
Chronic diarrhoea
Rapidly increasing head circumference

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7
Q

Which 3 symptoms warrant same day referral in GOR?

A

Haematemesis
Melaena
Dysphagia

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8
Q

Recall 6 factors prompting referral for paediatric assessment for GOR

A

Red flags

Faltering growth

Unexplained IDA

No improvement after 1y

Feeding aversion

Suspected Sandifer’s syndrome

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9
Q

What is Sandifers syndrome?

A

GORD
+
Paroxysmal dystonia: head, neck, back- Torticollis + Opisthotonus

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10
Q

Recall the general advice for GOR

A
  1. Reassure
  2. Review feeding hx
  3. Reduce feed volumes if excessive for infant’s weight
  4. Must sleep on back
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11
Q

For formula fed infants, what other management strategies should be used for GOR

A

Smaller more frequent feed
Offer thickened formula
Trial alginate 1-2w e.g. Gaviscon infant

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12
Q

For breastfed infants, what other management strategies should be used for GOR

A

Assess breast feeding- position, frequency

Trial Alginate 1-2w

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13
Q

What pharmacological treatment can be used if conservative management is ineffective for GOR?

A

PPI e.g. Omeprazole suspension
H2 receptor antagonists

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14
Q

What safety net should you watch out for when assessing GORD?

A

Monitor vomit: if bloody or green seek medical attention

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15
Q

What is necrotising enterocolitis?

A

Ischaemic necrosis of intestinal mucosa a/w severe inflammation, invasion of enteric gas forming organisms + dissection of gas into bowel wall

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16
Q

What is the major risk factor for necrotising enterocolitis?

A

Prematurity

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17
Q

Give 4 signs/ symptoms of necrotising enterocolitis

A

Abdo distension + erythema
Bloody stools
Bilious vomiting
Feeding intolerance

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18
Q

Give 2 complications of necrotising enterocolitis

A

Perforation + Peritonitis

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19
Q

What investigation is used to diagnose necrotising enterocolitis? What is seen?

A

Abdo XR
Intramural gas (pneumatosis intestinalis)
Pneumoperitoneum (perforation)
Air inside + outside bowel wall (Rigler sign)
Sentinel bowel loops

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20
Q

What is the treatment of necrotising enterocolitis?

A

Total bowel rest + TPN
Gastric decompression
Abx
Surgery: laparotomy for perforation

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21
Q

What causes pyloric stenosis? At what age does pyloric stenosis present?

A

hypertrophy of the circular muscles of the pylorus.
2-8w

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22
Q

Is pyloric stenosis more common in girls or boys?

A

Boys (4 x more common)

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23
Q

What is the main symptom of pyloric stenosis?

A

Projectile, non-billious vomiting
~30m after feed
Baby remains hungry
Increases in intensity until it becomes projectile

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24
Q

Recall 3 symptoms of pyloric stenosis other than vomiting

A

Weight loss + persistent hunger
Depressed fontanelle from dehydration
Constipation/ infrequent bowel movements

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25
Q

Recall some signs of pyloric stenosis

A

Palpable ‘olive’ mass
Visible peristalsis in upper abdomen

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26
Q

What will be the acid-base profile in pyloric stenosis?

A

Hypochloraemic, hypokalaemic metabolic alkalosis
due to persistent vomiting
may progress to a dehydrated lactic acidosis (opposite biochemial picture)

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27
Q

What is the best investigation for pyloric stenosis?

A

USS: shows target lesion of >3mm thickness
Do CBG to guide management

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28
Q

How should pyloric stenosis be managed?

A
  1. IV slow fluid resuscitation + correct any disturbances:
    1.5 x maintenance rate
    5% dextrose
    0.9% saline
  2. Laparoscopic Ramstedt pyloromyotomy
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29
Q

What are the symptoms of colic?

A

Inconsolable crying- worse in evening
Drawing up knees + arching back
Clenching fists

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30
Q

What is colic?

A

Repeated episodes of excessive + inconsolable crying in an infant that is otherwise healthy + thriving
<5 months when Sx start + stop.

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31
Q

What is management of colic?

A

Reassurance: strategies to sooth baby: holding baby, gentle motion, white noise, winding
Encourage parental wellbeing
Encourage to continue breastfeeding

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32
Q

What should be considered if the colic is persistent?

A

Cow’s milk protein allergy or reflux
Try:
2 week trial of hydrosylate formula followed by
2 week trial of anti-reflux tx

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33
Q

In what age group is appendicitis less common, and what is a more likely cause of similar symptoms in this age group?

A

Rare in under 3s, then it’s more likely to be faecolith (stony mass of impacted faeces)

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34
Q

Recall the management of appendicitis in children

A

GAME
G: group + save
A: Abx IV
M: MRSA screen
E: eat + drink NBM

Then laparoscopic appendectomy

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35
Q

What is intussusception?

A

Invagination of proximal bowel into distant component (telescoping distally)

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36
Q

What is the most common site of intussusception?

A

Ileum through to caecum through ileocaecal valve

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37
Q

Recall the appearance of stool in intussusception, and the pathophysiology of how this happens

A

Red-currant jelly (blood + mucus) due to venous obstruction + compression –> oedema + mucosal bleeding
This is a LATE sign

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38
Q

What are the causes of intussusception?

A

Idiopathic
Physiological lead point: Peyer’s patch
Pathological lead point: malignancy, Meckl’s diverticulum, Henoch-Schonlein purpura

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39
Q

What are the symptoms of intussusception?

A

Intermittent colicky pain
Vomit: depending on type: may be bile-stained or not

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40
Q

What are the signs of intussusception?

A

Abdominal distention with sausage shaped mass in RUQ
Emptiness on palpation in RLQ (Dance’s sign)
Red-currant jelly stool is a late sign

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41
Q

What are the appropriate investigations for intussusception?

A
  1. Abdo USS: may show donut sign (think: intUSSusception)
  2. AXR (may be normal)
  3. Barium/ gastrogaffin enema if have 1 of 3 Ps: Perforation, Peritonitis, Pale complexion
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42
Q

How should intussusception be managed?

A

It’s an emergency

If stable:
- Fluid resuscitation
- Enema: pneumatic - forces bowel to un-telescope - take x rays throughout

If unstable:
- Don’t mess about with contrast, go in with open surgery
- Remove any non-viable bowel

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43
Q

What should be done if there is recurrent intussusception?

A

Investigate for a lead point

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44
Q

What is Meckel’s diverticulum?

A

Congenital diverticulum of small intestine
Remnant of the omphalomesenteric duct (vitello-intestinal duct)
Contains ectopic ileal, gastric or pancreatic mucosa.

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45
Q

What is the rule used to remember all you need to know about Meckel’s diverticulum?

A

Rule of twos
2 years old
2 x more common in boys
2 feet from ileocaecal valve
2 inches long
2 different mucosae (gastric + pancreatic)

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46
Q

What are the signs and symptoms of meckel’s diverticulum?

A

Mostly asymptomatic
Painless massive PR bleeding
Abdo pain mimicking appendicitis
Intestinal obstruction: billious vomiting, dehydration + intractable constipation

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47
Q

What is the most common cause of painless massive GI bleedingin in children between ages 1-2?

A

Meckels diverticulum

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48
Q

How should meckel’s diverticulum be investigated if a child is stable?

A

99m Technetium pertechnetate scan indicates increased uptake by gastric mucosa

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49
Q

How should meckel’s diverticulum be investigated if a child is unstable and transfusion is required?

A

Mesenteric arteriography

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50
Q

How should meckel’s diverticulum be managed?

A

If asymptomatic, leave it alone!

If symptomatic:
Laparoscopic resection (excision of diverticulum)
+/- lysis of adhesions
Blood transfusion

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51
Q

How may volvulus present?

A
  1. At any age, after lying quiescent for ages
  2. In first few days of life, with obstruction + possible compromised blood supply –> abdo pain, billious vomiting, peritonism etc
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52
Q

What is the main sign of volvulus on abdo examination?

A

Scaphoid abdomen

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53
Q

How should volvulus be investigated?

A
  1. Upper GI contrast study (urgently) to assess patency if billious vomiting
  2. USS
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54
Q

How should volvulus be managed?

A

Urgent laparotomy
Untwist volvulus, mobilise the duodenum, place bowel in a good position + remove any necrotic bowel

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55
Q

What is the first thing to exclude in suspected IBS?

A

Coeliac

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56
Q

Recall the signs and symptoms of IBS

A

Abdo pain: often worse before or relieved by defaecation
Explosive loose or mucus stools
Bloating
Tenesmus
Constipation

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57
Q

Recall the 3 most common causes of paediatric gastroenteritis in decreasing prevalence

A
  1. Rotavirus
  2. Campylobacter
  3. Shigella/ salmonella
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58
Q

If there is bloody diarrhoea in gastroenteritis, which microbes should be considered first?

A

CHESS organisms:
Campylobacter
Hemorrhagic E coli
Entamoeba histolytica
Salmonella
Shigella

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59
Q

What investigations should be done in a case of gastroenteritis?

A

AXR to exclude other causes
Stool sample analysis
for viruses = stool electron microscopy
for bacteria = stool culture

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60
Q

How should paediatric gastroeneteritis be managed?

A

Rehydration

Learn maintenance fluid volumes:
0-10 kg = 100mls/kg

10-20kgs = 1000mls + 50ml/kg for each kg over 10kg

20+ kgs = 1500mls + 20 mls/kg for each kg over 20kgs

If <5 use IV fluids + maintain with oral rehydration solution

If >5, give 200mls after each

61
Q

What is the safety netting for how long vomiting and diarrhoea should last?

A

Vomiting: usually 1-2 days, must stop within 3 days

Diarrhoea: 5-7 days, must stop within 2 weeks

62
Q

What is the most accurate marker of dehydration in children?

A

Weight loss

63
Q

What is the threshold marker of dehydration for clinical dehydration and shock?

A

5-10% weight loss = clinical dehydration
>10% weight loss = shock

64
Q

Recall the symptoms of hypernatraemia

A

Mnemonic: f(ull) of salt
Flushing

Oedema
Fever

Seizures
Agitation
Low urine output
Thirst

65
Q

Recall the symptoms of hyponatraemia

A

SALT LOSS
Stupor
Anorexia
Limp tone
Tendon reflexes reduced

Lethargy
Orthostatic hypotension
Seizures
Stomach cramps

66
Q

When are IV fluids (rather than ORS) indicated?

A

Shock
Deterioration
Persistent vomiting

67
Q

What are the bolus fluids given in shock?

A

20mls/kg 0.9% saline over 15 mins (most situations)

10mls/kg 0.9% saline over 60 mins (trauma, fluid overload, heart failure)

68
Q

Recall the day 1, 2, 3, 4, and 5 fluid resucitation requirements in neonates

A

Day 1: 50-60mls/kg/day

Day 2: 70-80mls/kg/day

Day 3: 80-100mls/kg/day

Day 4: 100-120mls/kg/day

Day 5: 120-150mls/kg/day

69
Q

Which type of fluid should be used in fluid resus for term neonates?

A

Isotonic crystalloids with 10% dextrose

70
Q

If giving IV fluids to a hypernatraemic child, what should be the biggest caution?

A

Take care with cerebral oedema
Rapid reduction in plasma sodium concentration + osmolality will lead to a shift of water into cerebral cells
May result in seizures + cerebral oedema

71
Q

When should Abx be used in gastroenteritis?

A

Not even indicated when cause is bacterial

Use when:
- SEPSIS
- salmonella < 6 months
- C difficile with pseudomembranous colitis

72
Q

What is the post-gastroenteritis syndrome and how can it be treated?

A

Introduction of a normal diet results in a return of watery diarrhoea

Treat with oral rehydration therapy

73
Q

What would be seen on biopsy in Crohn’s?

A

Non-caseating epitheloid cell granulomata

74
Q

Recall some important investigations to do for Crohn’s disease

A
  1. FBC including iron, folate and B12
  2. Faecal calprotectin
  3. Colonoscopy + biopsy (cobblestones)
75
Q

How should Crohn’s be treated?

A

Induce remission:
Nutritional management
Replace diet with whole protein modular diet: excessively liquid, for 6-8 weeks.
The products are easily-digested and replace lost weight

Pharmacological management: steroids (prednisolone)

76
Q

What is the classical presentation of UC?

A

Rectal bleeding
Diarrhoea
Abdo pain

77
Q

What are the appropriate investigations to do in ulcerative colitis?

A

Same as Crohn’s

  1. FBC including iron, folate + B12
  2. Faecal calprotectin
  3. Colonoscopy + biopsy
78
Q

What does histology reveal in UC?

A

Mucosal inflammation/ ulceration
Crypt damage

79
Q

What scores can be used to score paediatric UC?

A

Paediatric UC Activity Index
Truelove + Witts

80
Q

What is one coexisting condition that it’s important to be aware of in ulcerative colitis?

A

Depression

81
Q

How should UC be managed?

A

1st line = oral aminosalicylates: may also be used to maintain remission
2nd line - oral corticosteroid
3rd line = oral tacrolimus
Surgery in resistant disease

82
Q

When does UC become an emergency?

A

In severe fulminating disease

83
Q

What is the usual cause of toddler diarrhoea?

A

Underlying maturational delay in intestinal mobility

84
Q

Recall some signs and symptoms of toddler diarrhoea

A

Varying consistency stools: well-formed to explosive + loose, may have bits of undigested vegetable
Child will be well + thriving

85
Q

How is toddler diarrhoea managed?

A

Increase fibre + fat in diet (whole milk, yoghurts, cheese)
Avoid fruit juice + squash

86
Q

What is the first-line management of constipation?

A

All first line:
1. Advise behavioural interventions (eg schedueled toileting, bowel habit diary, reward system)
2. Advise diet + lifestyle (adequate fluid intake)
3. Medication:
step 1 = movicol paediatric plan (dose escalates for 2 weeks)
Step 2: maintain for 6 months

87
Q

Recall some important things to remember in PACES counselling for constipation

A

Explain movicol takes some time to work (dose increases over 2 weeks)
Encourage child sitting on loo after mealtimes to use reflex
Advise a star chart to aid motivation

88
Q

What is Hirschprung’s?

A

An absence of ganglion cells from the myenteric (Auerbach) + submucosal (Meissner’s) plexuses

Lumen is tonically contracted, causing a functional obstruction

89
Q

Recall 2 risk factors for Hirschprung’s

A

Down’s
Men2a

90
Q

How may Hirschprung’s present? (5)

A

Failure/ delay to pass meconium in first 24h
Explosive passage of liquid + foul stools
Abdo distension +/- enterocolitis
Vomiting +/- bile
Failure to thrive

91
Q

If Hirschprung’s doesn’t present in first few days of life, what may happen?

A

May then present in a week or two with life-threatening Hirschprung’s enterocolitis (C diff)

92
Q

What is the gold standard investigation for Hirschsprung’s?

A

Full-thickness rectal biopsy
Showing absence of ganglion cells

93
Q

What screening investigations may be performed in suspected Hirschprung’s?

A

Contrast enema XR: contracted distal bowel + dilated proximal bowel

(AXR: dilated colon + air-fluid levels)

94
Q

What is the initial management of Hirschprungs?

A

Bowel irrigation “rectal washouts”
IV fluids
BS Abx if enterocolitis

95
Q

What is the definitive management of Hirschsprung’s ?

A

Anorectal pull through (colostomy followed by anastomosing normally innervated bowel)

96
Q

What is meconium ileus?

A

bowel obstruction that occurs when meconium is even thicker + stickier than normal meconium

97
Q

What condition do most children presenting with meconium ileus have?

A

Cystic fibrosis

98
Q

How does meconium ileus present?

A

Delayed passage of meconium
Abdo distension (viscid meconium obstructs terminal ileum)
Bilious vomiting

99
Q

What investigations are required for meconium ileus?

A

X-ray: No fluid level (meconium viscus)
Contrast enema XR: shows blockage

100
Q

What is management for meconium ileus?

A

IV fluids
NG tube
Enema may dislodge meconium plugs
Surgery

101
Q

Recall the principles of management for anal fissure

A

Ensure stools are soft + easy to pass (conservative)
Increase dietary fibre + fluid intake
Anal hygeine
Safety net: seek further help if not healed within 2 weeks

102
Q

Recall all the principles of management for threadworm

A

Single dose of an anti-helminth (mebendazole) for the whole household

Advise rigorous hygeine for 2 weeks if on mebendazole, or 6 weeks if using hygeine measures alone

Exclusion from school/ nursery is not required

103
Q

What can cause a temporary lactase deficiency?

A

Gastroenteritis
Crohn’s
Coeliac
Alcoholism

104
Q

What should be excluded in suspected lactose intolerance?

A

Gastroenteritis (stool sample)
Crohn’s (faecal calprotectin)
Coeliac (anti-tTG/EMA)

105
Q

How is a diagnosis of lactose intolerance made?

A

It’s a clinical diagnosis
trial a 2 week lactose-free diet + see how Sx are
Breath hydrogen test: early rise in H2 following CHO ingestion

106
Q

How is secondary lactose intolerance managed?

A

Cut out dairy to allow time to heal

May need calcium + vit D supplements

Digestive enzymes can be taken in a capsule before eating lactose until gut matures/ heals

107
Q

Recall 2 genetic associations with Coeliac’s?

A

HLA DQ2 (95%), DQ8 (80%)

108
Q

Recall the symptoms of coeliac in children

A

Failure to thrive
Abdo distention
Bloating
Irritability

109
Q

When does coeliac disease first present in children?

A

8-24 months after introduction to wheat foods

110
Q

How is coeliac disease diagnosed?

A

Most sensitive = IgA TTG
Or (less sensitive) = IgA anti-EMA

111
Q

What other investigations are useful in coeliac disease?

A

FBC + blood smear to look for anaemia
In older children/ adults: OJD + biopsy can confirm dx
In younger kids: no histopathological confirmation

112
Q

How should coeliac disease be managed?

A

Cut out all wheat, rye + barley
Dietician referral + annual review
Support sources: Coeliac UK

113
Q

What might be 4 consequences of non-adherence to diet in coeliac disease?

A

Micronutrient deficiency
Osteoporosis
EATL
Hyposplenism (loss of lymphocytes in GIT)

114
Q

What is mesenteric adenitis?

A

Swollen lymph glands that cause temporary abdo pain following infection

115
Q

What are the signs and symptoms of mesenteric adenitis?

A

Abdo pain (may present similar to appendicitis: central-RIF)

N + V + D: leading to reduced appetite

Fever

Often preceded by URTI/ viral infection

116
Q

How should mesenteric adenitis be diagnosed?

A

Bloods: WCC + CRP
Urine dip
USS: enlarged LN
Usually dx of exclusion
Definitive dx= laparoscopy showing large mesenteric lymph nodes + normal appendix

117
Q

How should mesenteric adenitis be managed?

A

Simple analgesia
Safety net for increased pain, deterioration
1-4w Sx (up to 10w)

118
Q

What is the pathophysiology of an indirect inguinal hernia?

A

Towards end of pregnancy the process vaginalis allows passage of testicles from abdomen to scrotum
When this passage fails to close, abdo lining/ bowel can protrude through defect

119
Q

Recall the signs and symptoms of hernia

A

Scrotal sac enlarged, contains palpable loops of bowel, fluid (does not always transilluminate)
Swelling or bulge may be intermittent + can appear on crying or straining

120
Q

How is hernia diagnosed?

A

Clinical diagnosis
Examine supine + standing + try to reduce in order to determine type of hernia

121
Q

Recall 3 risk factors for umbilical hernia

A

Afro-caribbean
Down’s
Mucopolysaccharide diseases

122
Q

How should hernia be managed?

A

Correct urgently
1. If < 6 weeks old, correct <2 days
2. If < 6 months old, correct <2 weeks
3. If <6 year old, correct <2 months

123
Q

How does an umbilical granuloma appear?

A

Leaks + is watery

124
Q

How is umbilical granuloma treated?

A

With salt

125
Q

Where are femoral hernias located?

A

Beneath inguinal canal

126
Q

What is femoral hernia most similar to?

A

Indirect inguinal hernia

127
Q

What is gastroschisis?

A

Paraumbilical wall defect: abdominal contents outside body without a peritoneal covering
Needs immediate surgery

128
Q

What is omphalocele?

A

Bowel protruding out of the body with a peritoneal covering

129
Q

How should omphalocele be managed?

A

Closure starting immediately, finishing at 6-12 months

130
Q

What is encoparesis?

A

Soiling of underwear with stool in children who are past the age of toilet training

131
Q

What is the usual cause of encoparesis?

A

Constipation with overflow

132
Q

How should encopresis be managed?

A

Enquire about stressors, changes in medication, food intolerances etc

133
Q

What are the 2 most likely causes of liver failure in children <2 y/o?

A

HSV infection
Metabolic disease

134
Q

What is the most likely cause of acute liver failure in children >2 y/o?

A

Paracetamol OD

135
Q

What are the signs and symptoms of acute liver failure?

A

Jaundice
Coagulopathy
Hypoglycaemia
Electrolyte disturbance
Encephalopathy

136
Q

How should Acute liver failure be managed?

A

Referral to a national paediatric liver centre
To stabilise the child:
- IV dextrose (due to hypoglycaemia)
- broad spectrum Abx + anti-fungals to prevent sepsis
- IV vit K + PPIs to prevent haemorrhage
- Fluid restriction + mannitol

137
Q

Recall some features of poor liver prognosis

A

Shrinking liver
Falling transaminases
Rising bilirubin
Worsening coagulopathy

138
Q

How should hepatic encephalopathy be managed?

A

Reduce nitrogen with lactulose

139
Q

How should AI hepatitis be managed?

A

Prednisolone/ azothioprine

140
Q

How should sclerosing cholangitis be managed?

A

Ursodeoxycholic acid (aids bile flow)

141
Q

How should Wilson’s disease be managed?

A

Zinc (blocks intestinal Cu resorption)

Trientine/ penicillinamine (increases urinary Cu excretion)

Pyridoxine (vit B6, prevents peripheral neuropathy)

Symptomatic tx for tremor, dystonia + speech impediment

142
Q

How is non-alcoholic fatty liver disease managed in children?

A

Weight loss
Statins
Treatment of diabetes
Vit E + C
Ursodeoxycholic acid to improve bile flow

143
Q

How should paracetamol OD be managed?

A

<1 hour: activated charchoal, do paracetamol level 4 hours post ingestion, NAC if indicated

> 1 hour: do a paracetamol level, NAC if indicated

144
Q

What is duodenal atresia?

A

Congenital narrowing/ absence of duodenum causing intestinal obstruction

145
Q

What can suggest duodenal atresia pre-natally?

A

Polyhydramnios
Baby not able to swallow amniotic fluid well
Usually diagnosed at 20w scan

146
Q

Give 3 signs/ symptoms of duodenal atresia

A

Premature birth
Bilious vomiting
Abdo distension

147
Q

What is the management for duodenal atresia?

A

IV fluids + NG tube

Surgery: Duodeno-duodenostomy or duodeno-jejunostomy.

148
Q

What investigation is used for duodenal atresia? What may be seen?

A

Abdo X-ray/ USS
Double bubble sign

149
Q

What condition do 1/3 of children with duodenal atresia have?

A

Down syndrome

YR5 Specialties (27 decks)

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