Paeds GASTRO Flashcards
What is the cause of GOR in babies?
Inappropriate relaxation of the LOS (functional immaturity)
By when does GOR usuallly resolve?
12 months: if persistent, may be due to GORD
How is GOR diagnosed?
Clinical dx
24 hour LOS pH monitoring (it should remain > 4)
OGD
Recall the factors affecting choice to refer for GOR
Same day referral if haematemesis, melaena or dysphagia
Assess by paediatrician if there are:
1. Red flags (eg faltering growth)
2. Unexplained IDA
3. No improvement after 1 y/o
4. Feeding aversion
5. Suspected Sandifer’s syndrome
Refer if there are complications
Recall the management options for GOR
- Reassure: it’s v common!
- Must sleep on back
- If breast fed: assess breast-feeding, consider alginate for 1-2 weeks, if not: pharmacology
If formula-fed: review feeding hx, try a smaller, more frequent feed + thickened formula, if doesn’t work, try alginate
What safety net should you watch out for when assessing GORD?
Monitor vomit: if bloody or green seek medical attention
At what age does pyloric stenosis present?
2-8 weeks
Is pyloric stenosis more common in girls or boys?
Boys (4 x more common)
Recall a genetic association of pyloric stenosis
Turner’s syndrome
What is the main symptom of pyloric stenosis?
Projectile, non-billious vomiting
Recall 3 symptoms of pyloric stenosis other than vomiting
Weight loss
Depressed fontanelle from dehydration
Loss of interest in food
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 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 ABG to guide management
How should pyloric stenosis be managed?
- IV slow fluid resuscitation + correct any disturbances:
1.5 x maintenance rate
5% dextrose
0.45% saline - Laparoscopic Ramstedt pyloromyotomy
What are the symptoms of colic?
Inconsolable crying + drawing up of the hands + feet: child remains distressed between episodes
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 (ileo-colic) - 90% cases
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, Meckel’s diverticulum, Henoch-Schonlein purpura
Thought to have a seasonal occurrence with viral illness with inflammatory processes triggering abdominal inflammation.
What are the symptoms of intussusception?
Intermittent colicky pain
Vomit - depending on type: may be bile-stained or not
Bloody stools (may be a late sign)
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
Signs of peritonitis if intussusception has been present a long time
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
What would be a contraindication for an air contrast enema?
Signs of peritonitis or free fluid (perforation) on USS - requires urgent surgery
HSP present
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
Is intussusception more commonly seen in males or females?
Males (2:1 ratio)
What age is intussusception most commonly seen?
Between 5 and 12 months
What should be done if there is recurrent intussusception?
Investigate for a lead point
When are intussusceptions with lead points commonly seen?
In patients with:
HSP (intestinal wall haematoma)
CF (hypertrophied intestinal mucosal glands)
Lymphoma
Peyer’s patches (enlarged mesenteric lymph nodes) - seen in younger infants following respiratory or GI infection
What is Meckel’s diverticulum?
Ileal remnant of vitello-intestinal duct on anti-mesenteric border containing ectopic gastric mucosa or pancreatic tissue
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 if it bleeds
May show billious vomiting, dehydration + intractable constipation
How should meckel’s diverticulum be investigated?
Technetium scan indicates increased uptake by gastric mucosa
AXR or USS + laparoscopy
How should meckel’s diverticulum be managed?
If asymptomatic, leave it alone!
If symptomatic:
Bleeding: excise diverticulum with blood transfusion
Obstruction: excise diverticulum + lyse adhesions
Perforation/ peritonitis: Excise with perioperative Abx
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
Is there are gender predominance associated with Hirschprung’s?
Male 4:1 ratio
Recall 2 risk factors for Hirschprung’s
Down’s
Men2a
Recall some signs and symptoms of Hirschprung’s
Failure to pass meconium in first 24 hours
Explosive passage of liquid/ foul stools
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)
How should Hirschprung’s be investigated?
- AXR (if obstruction)
- Contrast enema (showing dilated distal + narrowed proximal segments)
- Definitive diagnosis is via suction-assisted full-thickness rectal biopsy showing absence of ganglion cells
When would an an enema be contraindicated in Hirschsprung’s?
If there are signs of perforation or peritonitis
What is the aetiology of Hirschsprung’s enterocolitis?
Proximal colonic dilatation secondary to obstruction (functional) with thinning of the colonic wall, bacterial overgrowth and translocation of the gut bacteria into the blood.
What is the management of Hirschprungs?
1st line: bowel irrigation
Also 1st line: endorectal pullthrough (colostomy followed by anastomosing normally innervated bowel)
What is the management of Hirschsprung’s enterocolitis?
Supportive fluid resuscitation
Decompression with NG tube (and rectal tube if needed)
Broad-spectrum Abx (with anaerobic coverage)
Surgery - definitive treatment
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 the consequences of non-adherence to diet in coeliac disease?
Micronutrient deficiency, osteoporosis, EATK, hyposplenism
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
Nausea + diarrhoea, leading to reduced appetite
Infectious picture
Often preceded by UTI
How should mesenteric adenitis be diagnosed?
Definitive dx= laparoscopy showing large mesenteric lymph nodes + normal appendix
More often dx of exclusion (exclude appendicitis with bloods, urine, MC+S)
How should mesenteric adenitis be managed?
Simple analgesia
Maybe Abx (but not routine)
Safety net for increased pain, deterioration
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
Is pyloric stenosis more common in girls or boys?
Boys (4 x more common)
What is the inheritance pattern of pyloric stenosis?
Polygenic
What is the incidence of pyloric stenosis?
0.3%
What is the race predilection of pyloric stenosis?
More common in Caucasian babies
What is a Ramstedt pyloromyotomy?
The procedure of choice for pyloric stenosis where the pyloric muscle is split longitudinally down to the mucosa. It is easily performed with minimal complications.
What is the classical triad of HUS?
Thrombocytopenia
Microangiopathic haemolytic uraemia
Acute renal failure
What is the most common cause of HUS in children?
E.coli 0157:H7 - causes bloody diarrhoea
What investigations should be done for HUS?
FBC
Blood film
Renal function and serum electrolytes
Stool specimens for culture - as commonly caused by gastroenteritis in children
What are the 5 main causes of dysentry?
CHESS Y
Campylobacter
Haemolytic E.coli (0157:H7)
Entamoeba (protozoa)
Shigella
Salmonella
Yersinia enterocolitica
Give some reasons for physiological jaundice at birth
- Hb release from RBCs as there is high [Hb] at birth
- RBC lifespan being 70 days rather than 120 days
- Breast milk jaundice (but not until after >24 hours)
- BR metabolism being less efficient in first few days of life
What is the main danger of uBR buildup in neonates?
Kernicterus - a form of encephalopathy
What is kernicterus?
A form of encephalopathy caused by a deposit of uBR in the basal ganglia
May develop into dyskinetic CP, LD + sensorineural deafness
How can uBR buildup in neonates be treated before any damage is done?
Phototherapy +/- IvIG and exchange transfusion
What would be the difference in clinical presentation between uBR buildup and cBR buildup?
uBR buildup –> kernicterus
cBR buildup –> dark urine + pale stools
In what situations should phototherapy be stopped?
If bronzing occurs - means the child has a buildup of cBR, rather than uBR, which cannot be treated using phototherapy
How should investigations begin in neonatal jaundice?
- Check transcutaneous or serum BR levels
- Do a split BR to check uBR/cBR
- May want to do a blood film analysis
Recall some pathological causes of neonatal jaundice in babies <24 hours old
GRAPHIC DOG
- Gilbert’s
- Rhesus disease
- ABO incompatability (–> haemolysis)
- PK deficiency
- Hereditary spherocytosis
- Infection
- Crigler-Najjar
- Dubin-Johnson
- Other…
- G6PD deficiency
Recall 3 physiological causes of jaundice in a 2 day to 2 week old baby
Physiological jaundice
- due to immature liver, peaks at 3-5 days
Breastfeeding jaundice
- less milk intake –> more enterohepatic recycling
Breastmilk jaundice
- Decreased UGT1A1 activity (occurs following physiological jaundice)
What haemolytic and metabolic causes for jaundice might present in a 2 day to 2 week old baby?
Metabolic: Gilbert’s, Crigler-Najjar, Dubin-Johnson
Haemolytic: G6PDD, PK deficiency, hereditary spherocytosis (less likely to be ABO at this point)
What may be the cause of jaundice in a 2 day to 2 week old baby that didn’t present in first 24 hours?
Congenital hypothyroidism
Dehydration
Bruising (cephalohematoma)
Polycythaemia
How should jaundice be investigated in a baby over 2 weeks old?
Direct and indirect serum BR
Which of the conditions that cause jaundice in a 2 day to 2 week old baby might continue to the >2 weeks stage?
All - but physiological + breastmilk is most common
Recall 2 further causes of a buildup of uBR in a baby over 2 weeks old
Pyloric stenosis (presents at 2-4 weeks)
Congenital hypothyroidism*
Systematically recall the causes of a raised cBR in the neonate (>2w old)
Endocrine: Congenital hypothyroidism
GI: Billiary atresia, ascending cholangitis (can be caused by lipids on TPN)
Metabolic: Gal-1-PUT, A1AT deficiency, Tyrosinaemia type 1, peroxisomal disease
Other: CF, idiopathic neonatal hepatitis
Recall some investigations you might do to find the underlying cause of jaundice in a baby
TC/ serum BR within 6 hours of presentation
Haematocrit
DAT/ Coombs (haemolysis?)
G6PD levels (depending on ethnic origin)
TSH (hypothyroid?)
LFTs (ascending cholangitis? Biliary atresia?)
Blood group of M and B (ABO incompatible? Rhesus?)
Blood film + osmotic fragility (hereditary spherocytosis?)
MC&S of urine/ CSF (if ? infection cause)
For how long does jaundice have to persist in order to be defined as ‘prolonged’?
> 14 days if term
At what age should investigations include a split BR rather than just a total BR?
2 weeks
What is a worrying BR in a baby >37w gestation (red flag for kernicterus)?
> 340
Recall the clinical features of kernicterus
Poor feeding
Extreme lethargy
Hypotonia
High-pitched cry
How is treatment of neonatal jaundice guided?
There are thresholds at which phototherapy/ exchange transfusion are indicated
What are the options for treatment of neonatal jaundice?
Phototherapy +/- IV Ig
Exchange transfusion + phototherapy +/- IV Ig
How does phototherapy work?
Converts uBR to a water-soluble pigment that is excreted in urine
What important checks should be done during/ after phototherapy?
During: temperature, BR levels every 4-6 hours (with regular feed breaks)
After (12-18 hours post): check for a rebound hyperbilirubinaemia
When should intensive phototherapy be given?
- Rapidly rising BR
- Serum BR within 50mmol of exchange tranfusion threshold (after 72 hours life)
- BR level doesn’t respond after 6 hours of therapy
What are the 2 indications for exchange transfusion to treat neonatal jaundice?
- BR threshold reached
- Signs of kernicterus
What is an important thing to remember when giving an exchange transfusion?
Give folic acid afterwards to prevent anaemia
