Paeds GASTRO Flashcards
What is the commonest cause of vomiting in infancy?
Gastro-oesophageal reflux
What is the cause of GOR in babies?
Inappropriate relaxation of the LOS (functional immaturity)
= a normal physiological process in infancy
Affects >40% infants
When does GOR present? By when does GOR usuallly resolve?
Usually develops before 8w
12 months: if persistent, may be due to GORD
How does GOR present?
Vomiting/ regurgitation: milky vomits after feeds
Vomiting may occur after being laid flat
Excessive crying, esp. while feeding
How is GOR diagnosed?
Clinical dx
24h LOS pH
What are 6 symptoms are considered red flags suggesting disorders other than GOR?
Projectile vomiting
Bilious vomiting
Onset after 6m/ persisting after 1y
Abdo distension/ mass
Chronic diarrhoea
Rapidly increasing head circumference
Which 3 symptoms warrant same day referral in GOR?
Haematemesis
Melaena
Dysphagia
Recall 6 factors prompting referral for paediatric assessment for GOR
Red flags
Faltering growth
Unexplained IDA
No improvement after 1y
Feeding aversion
Suspected Sandifer’s syndrome
What is Sandifers syndrome?
GORD
+
Paroxysmal dystonia: head, neck, back- Torticollis + Opisthotonus
Recall the general advice for GOR
- Reassure
- Review feeding hx
- Reduce feed volumes if excessive for infant’s weight
- Must sleep on back
For formula fed infants, what other management strategies should be used for GOR
Smaller more frequent feed
Offer thickened formula
Trial alginate 1-2w e.g. Gaviscon infant
For breastfed infants, what other management strategies should be used for GOR
Assess breast feeding- position, frequency
Trial Alginate 1-2w
What pharmacological treatment can be used if conservative management is ineffective for GOR?
PPI e.g. Omeprazole suspension
H2 receptor antagonists
What safety net should you watch out for when assessing GORD?
Monitor vomit: if bloody or green seek medical attention
What is necrotising enterocolitis?
Ischaemic necrosis of intestinal mucosa a/w severe inflammation, invasion of enteric gas forming organisms + dissection of gas into bowel wall
What is the major risk factor for necrotising enterocolitis?
Prematurity
Give 4 signs/ symptoms of necrotising enterocolitis
Abdo distension + erythema
Bloody stools
Bilious vomiting
Feeding intolerance
Give 2 complications of necrotising enterocolitis
Perforation + Peritonitis
What investigation is used to diagnose necrotising enterocolitis? What is seen?
Abdo XR
Intramural gas (pneumatosis intestinalis)
Pneumoperitoneum (perforation)
Air inside + outside bowel wall (Rigler sign)
Sentinel bowel loops
What is the treatment of necrotising enterocolitis?
Total bowel rest + TPN
Gastric decompression
Abx
Surgery: laparotomy for perforation
What causes pyloric stenosis? At what age does pyloric stenosis present?
hypertrophy of the circular muscles of the pylorus.
2-8w
Is pyloric stenosis more common in girls or boys?
Boys (4 x more common)
What is the main symptom of pyloric stenosis?
Projectile, non-billious vomiting
~30m after feed
Baby remains hungry
Increases in intensity until it becomes projectile
Recall 3 symptoms of pyloric stenosis other than vomiting
Weight loss + persistent hunger
Depressed fontanelle from dehydration
Constipation/ infrequent bowel movements
Recall some signs of pyloric stenosis
Palpable ‘olive’ mass
Visible peristalsis in upper abdomen
What will be the acid-base profile in pyloric stenosis?
Hypochloraemic, hypokalaemic metabolic alkalosis
due to persistent vomiting
may progress to a dehydrated lactic acidosis (opposite biochemial picture)
What is the best investigation for pyloric stenosis?
USS: shows target lesion of >3mm thickness
Do CBG to guide management
How should pyloric stenosis be managed?
- IV slow fluid resuscitation + correct any disturbances:
1.5 x maintenance rate
5% dextrose
0.9% saline - Laparoscopic Ramstedt pyloromyotomy
What are the symptoms of colic?
Inconsolable crying- worse in evening
Drawing up knees + arching back
Clenching fists
What is colic?
Repeated episodes of excessive + inconsolable crying in an infant that is otherwise healthy + thriving
<5 months when Sx start + stop.
What is management of colic?
Reassurance: strategies to sooth baby: holding baby, gentle motion, white noise, winding
Encourage parental wellbeing
Encourage to continue breastfeeding
What should be considered if the colic is persistent?
Cow’s milk protein allergy or reflux
Try:
2 week trial of hydrosylate formula followed by
2 week trial of anti-reflux tx
In what age group is appendicitis less common, and what is a more likely cause of similar symptoms in this age group?
Rare in under 3s, then it’s more likely to be faecolith (stony mass of impacted faeces)
Recall the management of appendicitis in children
GAME
G: group + save
A: Abx IV
M: MRSA screen
E: eat + drink NBM
Then laparoscopic appendectomy
What is intussusception?
Invagination of proximal bowel into distant component (telescoping distally)
What is the most common site of intussusception?
Ileum through to caecum through ileocaecal valve
Recall the appearance of stool in intussusception, and the pathophysiology of how this happens
Red-currant jelly (blood + mucus) due to venous obstruction + compression –> oedema + mucosal bleeding
This is a LATE sign
What are the causes of intussusception?
Idiopathic
Physiological lead point: Peyer’s patch
Pathological lead point: malignancy, Meckl’s diverticulum, Henoch-Schonlein purpura
What are the symptoms of intussusception?
Intermittent colicky pain
Vomit: depending on type: may be bile-stained or not
What are the signs of intussusception?
Abdominal distention with sausage shaped mass in RUQ
Emptiness on palpation in RLQ (Dance’s sign)
Red-currant jelly stool is a late sign
What are the appropriate investigations for intussusception?
- Abdo USS: may show donut sign (think: intUSSusception)
- AXR (may be normal)
- Barium/ gastrogaffin enema if have 1 of 3 Ps: Perforation, Peritonitis, Pale complexion
How should intussusception be managed?
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
What should be done if there is recurrent intussusception?
Investigate for a lead point
What is Meckel’s diverticulum?
Congenital diverticulum of small intestine
Remnant of the omphalomesenteric duct (vitello-intestinal duct)
Contains ectopic ileal, gastric or pancreatic mucosa.
What is the rule used to remember all you need to know about Meckel’s diverticulum?
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)
What are the signs and symptoms of meckel’s diverticulum?
Mostly asymptomatic
Painless massive PR bleeding
Abdo pain mimicking appendicitis
Intestinal obstruction: billious vomiting, dehydration + intractable constipation
What is the most common cause of painless massive GI bleedingin in children between ages 1-2?
Meckels diverticulum
How should meckel’s diverticulum be investigated if a child is stable?
99m Technetium pertechnetate scan indicates increased uptake by gastric mucosa
How should meckel’s diverticulum be investigated if a child is unstable and transfusion is required?
Mesenteric arteriography
How should meckel’s diverticulum be managed?
If asymptomatic, leave it alone!
If symptomatic:
Laparoscopic resection (excision of diverticulum)
+/- lysis of adhesions
Blood transfusion
How may volvulus present?
- At any age, after lying quiescent for ages
- In first few days of life, with obstruction + possible compromised blood supply –> abdo pain, billious vomiting, peritonism etc
What is the main sign of volvulus on abdo examination?
Scaphoid abdomen
How should volvulus be investigated?
- Upper GI contrast study (urgently) to assess patency if billious vomiting
- USS
How should volvulus be managed?
Urgent laparotomy
Untwist volvulus, mobilise the duodenum, place bowel in a good position + remove any necrotic bowel
What is the first thing to exclude in suspected IBS?
Coeliac
Recall the signs and symptoms of IBS
Abdo pain: often worse before or relieved by defaecation
Explosive loose or mucus stools
Bloating
Tenesmus
Constipation
Recall the 3 most common causes of paediatric gastroenteritis in decreasing prevalence
- Rotavirus
- Campylobacter
- Shigella/ salmonella
If there is bloody diarrhoea in gastroenteritis, which microbes should be considered first?
CHESS organisms:
Campylobacter
Hemorrhagic E coli
Entamoeba histolytica
Salmonella
Shigella
What investigations should be done in a case of gastroenteritis?
AXR to exclude other causes
Stool sample analysis
for viruses = stool electron microscopy
for bacteria = stool culture
How should paediatric gastroeneteritis be managed?
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
What is the safety netting for how long vomiting and diarrhoea should last?
Vomiting: usually 1-2 days, must stop within 3 days
Diarrhoea: 5-7 days, must stop within 2 weeks
What is the most accurate marker of dehydration in children?
Weight loss
What is the threshold marker of dehydration for clinical dehydration and shock?
5-10% weight loss = clinical dehydration
>10% weight loss = shock
Recall the symptoms of hypernatraemia
Mnemonic: f(ull) of salt
Flushing
Oedema
Fever
Seizures
Agitation
Low urine output
Thirst
Recall the symptoms of hyponatraemia
SALT LOSS
Stupor
Anorexia
Limp tone
Tendon reflexes reduced
Lethargy
Orthostatic hypotension
Seizures
Stomach cramps
When are IV fluids (rather than ORS) indicated?
Shock
Deterioration
Persistent vomiting
What are the bolus fluids given in shock?
20mls/kg 0.9% saline over 15 mins (most situations)
10mls/kg 0.9% saline over 60 mins (trauma, fluid overload, heart failure)
Recall the day 1, 2, 3, 4, and 5 fluid resucitation requirements in neonates
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
Which type of fluid should be used in fluid resus for term neonates?
Isotonic crystalloids with 10% dextrose
If giving IV fluids to a hypernatraemic child, what should be the biggest caution?
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
When should Abx be used in gastroenteritis?
Not even indicated when cause is bacterial
Use when:
- SEPSIS
- salmonella < 6 months
- C difficile with pseudomembranous colitis
What is the post-gastroenteritis syndrome and how can it be treated?
Introduction of a normal diet results in a return of watery diarrhoea
Treat with oral rehydration therapy
What would be seen on biopsy in Crohn’s?
Non-caseating epitheloid cell granulomata
Recall some important investigations to do for Crohn’s disease
- FBC including iron, folate and B12
- Faecal calprotectin
- Colonoscopy + biopsy (cobblestones)
How should Crohn’s be treated?
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)
What is the classical presentation of UC?
Rectal bleeding
Diarrhoea
Abdo pain
What are the appropriate investigations to do in ulcerative colitis?
Same as Crohn’s
- FBC including iron, folate + B12
- Faecal calprotectin
- Colonoscopy + biopsy
What does histology reveal in UC?
Mucosal inflammation/ ulceration
Crypt damage
What scores can be used to score paediatric UC?
Paediatric UC Activity Index
Truelove + Witts
What is one coexisting condition that it’s important to be aware of in ulcerative colitis?
Depression
How should UC be managed?
1st line = oral aminosalicylates: may also be used to maintain remission
2nd line - oral corticosteroid
3rd line = oral tacrolimus
Surgery in resistant disease
When does UC become an emergency?
In severe fulminating disease
What is the usual cause of toddler diarrhoea?
Underlying maturational delay in intestinal mobility
Recall some signs and symptoms of toddler diarrhoea
Varying consistency stools: well-formed to explosive + loose, may have bits of undigested vegetable
Child will be well + thriving
How is toddler diarrhoea managed?
Increase fibre + fat in diet (whole milk, yoghurts, cheese)
Avoid fruit juice + squash
What is the first-line management of constipation?
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
Recall some important things to remember in PACES counselling for constipation
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
What is Hirschprung’s?
An absence of ganglion cells from the myenteric (Auerbach) + submucosal (Meissner’s) plexuses
Lumen is tonically contracted, causing a functional obstruction
Recall 2 risk factors for Hirschprung’s
Down’s
Men2a
How may Hirschprung’s present? (5)
Failure/ delay to pass meconium in first 24h
Explosive passage of liquid + foul stools
Abdo distension +/- enterocolitis
Vomiting +/- bile
Failure to thrive
If Hirschprung’s doesn’t present in first few days of life, what may happen?
May then present in a week or two with life-threatening Hirschprung’s enterocolitis (C diff)
What is the gold standard investigation for Hirschsprung’s?
Full-thickness rectal biopsy
Showing absence of ganglion cells
What screening investigations may be performed in suspected Hirschprung’s?
Contrast enema XR: contracted distal bowel + dilated proximal bowel
(AXR: dilated colon + air-fluid levels)
What is the initial management of Hirschprungs?
Bowel irrigation “rectal washouts”
IV fluids
BS Abx if enterocolitis
What is the definitive management of Hirschsprung’s ?
Anorectal pull through (colostomy followed by anastomosing normally innervated bowel)
What is meconium ileus?
bowel obstruction that occurs when meconium is even thicker + stickier than normal meconium
What condition do most children presenting with meconium ileus have?
Cystic fibrosis
How does meconium ileus present?
Delayed passage of meconium
Abdo distension (viscid meconium obstructs terminal ileum)
Bilious vomiting
What investigations are required for meconium ileus?
X-ray: No fluid level (meconium viscus)
Contrast enema XR: shows blockage
What is management for meconium ileus?
IV fluids
NG tube
Enema may dislodge meconium plugs
Surgery
Recall the principles of management for anal fissure
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
Recall all the principles of management for threadworm
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
What can cause a temporary lactase deficiency?
Gastroenteritis
Crohn’s
Coeliac
Alcoholism
What should be excluded in suspected lactose intolerance?
Gastroenteritis (stool sample)
Crohn’s (faecal calprotectin)
Coeliac (anti-tTG/EMA)
How is a diagnosis of lactose intolerance made?
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
How is secondary lactose intolerance managed?
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
Recall 2 genetic associations with Coeliac’s?
HLA DQ2 (95%), DQ8 (80%)
Recall the symptoms of coeliac in children
Failure to thrive
Abdo distention
Bloating
Irritability
When does coeliac disease first present in children?
8-24 months after introduction to wheat foods
How is coeliac disease diagnosed?
Most sensitive = IgA TTG
Or (less sensitive) = IgA anti-EMA
What other investigations are useful in coeliac disease?
FBC + blood smear to look for anaemia
In older children/ adults: OJD + biopsy can confirm dx
In younger kids: no histopathological confirmation
How should coeliac disease be managed?
Cut out all wheat, rye + barley
Dietician referral + annual review
Support sources: Coeliac UK
What might be 4 consequences of non-adherence to diet in coeliac disease?
Micronutrient deficiency
Osteoporosis
EATL
Hyposplenism (loss of lymphocytes in GIT)
What is mesenteric adenitis?
Swollen lymph glands that cause temporary abdo pain following infection
What are the signs and symptoms of mesenteric adenitis?
Abdo pain (may present similar to appendicitis: central-RIF)
N + V + D: leading to reduced appetite
Fever
Often preceded by URTI/ viral infection
How should mesenteric adenitis be diagnosed?
Bloods: WCC + CRP
Urine dip
USS: enlarged LN
Usually dx of exclusion
Definitive dx= laparoscopy showing large mesenteric lymph nodes + normal appendix
How should mesenteric adenitis be managed?
Simple analgesia
Safety net for increased pain, deterioration
1-4w Sx (up to 10w)
What is the pathophysiology of an indirect inguinal hernia?
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
Recall the signs and symptoms of hernia
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
How is hernia diagnosed?
Clinical diagnosis
Examine supine + standing + try to reduce in order to determine type of hernia
Recall 3 risk factors for umbilical hernia
Afro-caribbean
Down’s
Mucopolysaccharide diseases
How should hernia be managed?
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
How does an umbilical granuloma appear?
Leaks + is watery
How is umbilical granuloma treated?
With salt
Where are femoral hernias located?
Beneath inguinal canal
What is femoral hernia most similar to?
Indirect inguinal hernia
What is gastroschisis?
Paraumbilical wall defect: abdominal contents outside body without a peritoneal covering
Needs immediate surgery
What is omphalocele?
Bowel protruding out of the body with a peritoneal covering
How should omphalocele be managed?
Closure starting immediately, finishing at 6-12 months
What is encoparesis?
Soiling of underwear with stool in children who are past the age of toilet training
What is the usual cause of encoparesis?
Constipation with overflow
How should encopresis be managed?
Enquire about stressors, changes in medication, food intolerances etc
What are the 2 most likely causes of liver failure in children <2 y/o?
HSV infection
Metabolic disease
What is the most likely cause of acute liver failure in children >2 y/o?
Paracetamol OD
What are the signs and symptoms of acute liver failure?
Jaundice
Coagulopathy
Hypoglycaemia
Electrolyte disturbance
Encephalopathy
How should Acute liver failure be managed?
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
Recall some features of poor liver prognosis
Shrinking liver
Falling transaminases
Rising bilirubin
Worsening coagulopathy
How should hepatic encephalopathy be managed?
Reduce nitrogen with lactulose
How should AI hepatitis be managed?
Prednisolone/ azothioprine
How should sclerosing cholangitis be managed?
Ursodeoxycholic acid (aids bile flow)
How should Wilson’s disease be managed?
Zinc (blocks intestinal Cu resorption)
Trientine/ penicillinamine (increases urinary Cu excretion)
Pyridoxine (vit B6, prevents peripheral neuropathy)
Symptomatic tx for tremor, dystonia + speech impediment
How is non-alcoholic fatty liver disease managed in children?
Weight loss
Statins
Treatment of diabetes
Vit E + C
Ursodeoxycholic acid to improve bile flow
How should paracetamol OD be managed?
<1 hour: activated charchoal, do paracetamol level 4 hours post ingestion, NAC if indicated
> 1 hour: do a paracetamol level, NAC if indicated
What is duodenal atresia?
Congenital narrowing/ absence of duodenum causing intestinal obstruction
What can suggest duodenal atresia pre-natally?
Polyhydramnios
Baby not able to swallow amniotic fluid well
Usually diagnosed at 20w scan
Give 3 signs/ symptoms of duodenal atresia
Premature birth
Bilious vomiting
Abdo distension
What is the management for duodenal atresia?
IV fluids + NG tube
Surgery: Duodeno-duodenostomy or duodeno-jejunostomy.
What investigation is used for duodenal atresia? What may be seen?
Abdo X-ray/ USS
Double bubble sign
What condition do 1/3 of children with duodenal atresia have?
Down syndrome
