Paeds gastro conditions Flashcards
definiton of GORD
contents from the stomach reflux through the lower oesophageal sphincter into the oesophagus, throat and mouth
pathophysiology of GORD
In babies there is immaturity of the lower oesophageal sphincter, allowing stomach contents to easily reflux into the oesophagus. It is normal for a baby to reflux feeds, and provided there is normal growth and the baby is otherwise well this is not a problem, however it can be upsetting for parents
% of infants stop having reflux by
90% by 1 year
presentation of GORD
causes of vomiting
red flags in gastro symptoms in children
management of GORD
- sandifer’s syndrome definition and features
- sandifer’s syndrome management and differentials
The condition tends to resolve as the reflux is treated or improves. Generally the outcome is good. It is worth referring patients with these symptoms to a specialist for assessment, as the differential diagnosis includes more serious conditions such as infantile spasms (West syndrome) and seizures.
- Pathophysiology of pyloric stenosis
- Most prominent presentation in pyloric stenosis
projectile vomiting
- What age does pyloric stenosis typically present
Pyloric stenosis typically presents in the first few weeks of life
- Presentation in pyloric stenosis
Pyloric stenosis typically presents in the first few weeks of life, with a hungry baby that is thin, pale and generally failing to thrive. The classic description of vomiting you should remember for your exams is “projectile vomiting”.
- Examination findings in pyloric stenosis
If examined after feeding, often the peristalsis can be seen by observing the abdomen. A firm, round mass can be felt in the upper abdomen that “feels like a large olive”. This is caused by the hypertrophic muscle of the pylorus.
- How is pyloric stenosis diagnosed?
abdominal US
- Investigation findings in pyloric stenosis
Blood gas analysis will show a hypochloric (low chloride) metabolic alkalosis as the baby is vomiting the hydrochloric acid from the stomach
US abdo will show a thickened pylorus
- Management of pyloric stenosis
Treatment involves a laparoscopic pyloromyotomy (known as “Ramstedt’s operation“). An incision is made in the smooth muscle of the pylorus to widen the canal allowing that food to pass from the stomach to the duodenum as normal. Prognosis is excellent following the operation.
differentials to pyloric stenosis
- Appendicitis definition and pathophysiology
- Signs and symptoms of appendicitis
- …suggest peritonitis, caused by a ruptured appendix
Rebound tenderness and percussion tenderness
diagnosis of appendicitis
Key Differential Diagnoses of Appendicitis
management of appendicitis
Removal of the inflamed appendix (appendicectomy) is the definitive management for acute appendicitis. Laparoscopic surgery is associated with fewer risks and faster recovery compared to open surgery (laparotomy).
Complications of Appendicectomy
- Bleeding, infection, pain and scars
- Damage to bowel, bladder or other organs
- Removal of a normal appendix
- Anaesthetic risks
- Venous thromboembolism (deep vein thrombosis or pulmonary embolism)
Definition of intussusception and what it leads to
Intussusception is a condition where the bowel “invaginates” or “telescopes” into itself. Picture the bowel folding inwards. This thickens the overall size of the bowel and narrows the lumen at the folded area, leading to a palpable mass in the abdomen and obstruction to the passage of faeces through the bowel
age range when intussusception occurs
It typically occurs in infants 6 months to 2 years and is more common in boys.
intussusception is associated with various conditions:
- Concurrent viral illness
- Henoch-Schonlein purpura
- Cystic fibrosis
- Intestinal polyps
- Meckel diverticulum
- presentation of intussusception
diagnosis of intussusception
Diagnosis is made mainly by ultrasound scan or contrast enema.
management of intussusception
complications of intussusception
- Obstruction
- Gangrenous bowel
- Perforation
- Death
Typical features in the history and examination that suggest constipation are:
Encopresis is the term for
faecal incontinence
encopresis is not considered pathological until… years of age
until 4 years of age
It is usually a sign of chronic constipation where
It is usually a sign of 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.
Common cause of encopresis
It is usually a sign of 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.
rarer causes of encopresis
There are a number of lifestyle factors that can contribute to the development and continuation of constipation:
Pathophysiology of desensitisation of the rectum secondary to constipation
secondary causes of constipation
red flags of constipation in children
complications of constipation
how is constipation diagnosed
A diagnosis of idiopathic constipation can be made without investigations, provided red flags are considered. It is important to provide adequate explanation of the diagnosis and management as well as reassure parents about the absence of concerning underlying causes. Explain that treating constipation can be a prolonged process, potentially lasting months.
management of constipation
first line laxative used in children with constipation
Movicol
Differential diagnosis of diarrhoea
Key conditions to think about in patients with loose stools are:
Infection (gastroenteritis)
Inflammatory bowel disease
Lactose intolerance
Coeliac disease
Cystic fibrosis
Toddler’s diarrhoea
Irritable bowel syndrome
Medications (e.g. antibiotics)
Steatorrhoea means… This suggests a problem with…
Steatorrhoea means greasy stools with excessive fat content. This suggests a problem with digesting fats, such as pancreatic insufficiency (think about cystic fibrosis).
- What is the main concern with gastroenteritis and how is it managed?
Dehydration is the main concern. The key to management is establishing whether they are able to keep themselves hydrated or whether they need admission for IV fluids. Antibiotics are generally not recommended or required. Most children make a full recovery with simple supportive management, but beware gastroenteritis can potentially be fatal, especially in very young or vulnerable children with other health conditions.
The most common cause of gastroenteritis is
viral
Gastroenteritis is…presents with…
Gastroenteritis is inflammation all the way from the stomach to the intestines and presents with nausea, vomiting and diarrhoea.
Enteritis is…presents with
Enteritis is inflammation of the intestines and presents with diarrhoea.
Acute gastritis is…presents with
Acute gastritis is inflammation of the stomach and presents with nausea and vomiting
Viral gastroenteritis organism causes
Rotavirus
Norovirus
Adenovirus is a less common cause and presents with a more subacute diarrhoea.
Which strain of E.coli causes gastroenteritis and how is it spread?
E. coli 0157
It is spread through contact with infected faeces, unwashed salads or contaminated water.
How does E.coli lead to gastroenteritis and how does it present?
E. coli 0157 produces the Shiga toxin. This causes abdominal cramps, bloody diarrhoea and vomiting. The Shiga toxin destroys blood cells and leads to haemolytic uraemic syndrome (HUS).
antibiotics should be avoided if E. coli gastroenteritis is considered because…
The use of antibiotics increases the risk of haemolytic uraemic syndrome
the most common bacterial cause of gastroenteritis worldwide
Campylobacter is a common cause of travellers diarrhoea
what type of bacteria is campylobacter and how is it spread?
Incubation period and symptoms of campylobacter jejuni
Incubation is usually 2 to 5 days. Symptoms resolve after 3 to 6 days. Symptoms are:
Abdominal cramps
Diarrhoea often with blood
Vomiting
Fever
can antibiotics be used to treat campylobacter?
Antibiotics can be considered after isolating the organism where patients have severe symptoms or other risk factors such as HIV or heart failure.
Popular antibiotic choices are azithromycin or ciprofloxacin.
Shigella is spread by
Shigella is spread by faeces contaminating drinking water, swimming pools and food
Incubation period and symptoms of shigella
The incubation period is 1 to 2 days and symptoms usually resolve within 1 week without treatment. It causes bloody diarrhoea, abdominal cramps and fever. Shigella can produce the Shiga toxin and cause haemolytic uraemic syndrome.
Treatment of severe cases of shigella is with
Treatment of severe cases is with azithromycin or ciprofloxacin
Salmonella is spread by
Salmonella is spread by eating raw eggs or poultry, or food contaminated with the infected faeces of small animals
Incubation period and symptoms of salmonella
Incubation is 12 hours to 3 days and symptoms usually resolve within 1 week. Symptoms are watery diarrhoea that can be associated with mucus or blood, abdominal pain and vomiting.
can you use antibiotics to treat salmonella?
Antibiotics are only necessary in severe cases and should be guided by stool culture and sensitivities
The typical exam patient with bacillus cereus
The typical exam patient with bacillus cereus develops symptoms soon after eating leftover fried rice that has been left at room temperature. It has a short incubation period after eating the rice before symptoms occur, and they recover within 24 hours.
What type of organism is bacillus cereus and how is it spread?
Bacillus cereus is a gram positive rod spread through inadequately cooked food. It grows well on food not immediately refrigerated after cooking. The typical food is fried rice left out at room temperature.
Typical course and symptoms of bacillus cereus
Yersinia is what type of organism and how is it spread?
Yersinia is a gram negative bacillus. Pigs are key carriers of Yersinia, and eating raw or undercooked pork can cause infection. It is also spread through contamination with the urine or faeces of other mammal such as rats and rabbits.
Yersinia incubation and symptoms
Are antibiotics used to treat Yersinia
Antibiotics are only necessary in severe cases and should be guided by stool culture and sensitivities.
How does Staphylococcus aureus cause gastroenteritis?
Staphylococcus aureus can produce enterotoxins when growing on food such as eggs, dairy and meat. When eaten these toxins cause small intestine inflammation.
Symptoms and incubation period of staphylococcus aureus enterotoxin infection
symptoms of diarrhoea, perfuse vomiting, abdominal cramps and fever. These symptoms start within hours of ingestion and settle within 12 to 24 hours. It is not actually the bacteria causing the enteritis but the staphylococcus enterotoxin.
Giardia lamblia is what type of organisms and how is it spread?
Symptoms, diagnosis and treatment of giardia lamblia
Infection may not cause any symptoms, or it may cause chronic diarrhoea. Diagnosis is made by stool microscopy. Treatment is with metronidazole.
Investigations and management of gastroenteritis
How long should children stay off school if they have gastroenteritis
48h
post-gastroenteritis complications:
Lactose intolerance
Irritable bowel syndrome
Reactive arthritis
Guillain–Barré syndrome
General presenting features of IBD
Diarrhoea
Abdominal pain
Rectal bleeding
Fatigue
Weight loss or anemia
may be systemically unwell during flares, with fevers, malaise and dehydration
Ulcerative colitis’s vs Chron’s acronym
Extra intestinal manifestation of IBD
which extra intestinal manifestations are more common in UC vs Chron’s
Chron’s: Gallstones are more common secondary to reduced bile acid reabsorption
UC: Primary sclerosis cholangitis more common
Complications of Chron’s
Obstruction, fistula, colorectal cancer
Complications of UC
- fulminantcolitis
- significant haemorrhage
- toxicmegacolon
- colonic cancer
Risk of colorectal cancer high in UC than CD
pathology Chron’s vs UC
Chron’s
* Lesions may be seen anywhere from the mouth to anus
* Skip lesions may be present
UC
* Inflammation always starts at rectum and never spreads beyond ileocaecal valve
* Continuous disease
HIstology Chron’s vs UC
Chron’s
Inflammation in all layers from mucosa to serosa
increased goblet cells
granulomas
UC
No inflammation beyond submucosa (unless fulminant disease) - inflammatory cell infiltrate in lamina propria
* neutrophils migrate through the walls of glands to form crypt abscesses
* depletion of goblet cells and mucin from gland epithelium
* granulomas are infrequent
Endoscopy CD vs UC
CD
Deep ulcers, skip lesions - ‘cobble-stone’ appearance
UC
Widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’)
Radiology CD vs UC
CD
Small bowel enema
* high sensitivity and specificity for examination of the terminal ileum
* strictures: ‘Kantor’s string sign’
* proximal bowel dilation
* ‘rose thorn’ ulcers
* fistulae
UC
Barium enema
* loss of haustrations
* superficial ulceration, ‘pseudopolyps’
* long standing disease: colon is narrow and short -‘drainpipe colon’
Investigations for IBD
Gold standard investigation for IBD
Endoscopy (OGD and colonoscopy) with biopsy is the gold standard investigation for diagnosis of IBD.
management of Chron’s
Management of UC
general management of IBD
Mesenteric adenitits presentation and management
Mesenteric adenitis is inflamed lymph nodes within the mesentery. It can cause similar symptoms to appendicitis and can be difficult to distinguish between the two.
It often follows a recent viral infection and needs no treatment
Toddler’s diarrhea presentation and treatment
Stools containing ‘carrots and peas’ and undigested food –> toddlers diarrhoea or ‘chronic nonspecific diarrhoea’ in exams.
should remit as a child grows up, aged between 1 and 5-years-old and more common in boys.
diet often a contributor. Diarrhoea will remit given a good level of fat, less fruit juices or squash and receives a healthy amount of fibre in their diet.
Children with this condition must be healthy, untroubled by the diarrhoea and growing normally. If there are any abnormalities in the child’s general health it is important to investigate other possible causes.
Coeliac presentation
test all patients with a new diagnosis of…. for coeliac disease, even if they don’t have symptom, because the conditions are often linked
Type 1 diabetes
genes associated with coeliac disease
HLA-DQ2 gene (90%)
HLA-DQ8 gene
autoantibodies in coeliac
- Tissue transglutaminase antibodies (anti-TTG)
- Endomysial antibodies (EMAs)
- Deaminated gliadin peptides antibodies (anti-DGPs)
coeliac diagnosis/investigations
Endoscopy and intestinal biopsy in coeliac show:
“Crypt hypertrophy”
“Villous atrophy”
Coeliac disease is associated with many other conditions:
Type 1 diabetes
Thyroid disease
Autoimmune hepatitis
Primary biliary cirrhosis
Primary sclerosing cholangitis
Down’s syndrome
Complications of untreated coeliac disease
Treatment of coeliac
A lifelong gluten free diet is essentially curative. Relapse will occur on consuming gluten again. Checking coeliac antibodies can be helpful in monitoring the disease.
Coeliac pathophysiology
Presentation of biliary atresia
presents shortly after birth with significant jaundice due to high conjugated bilirubin levels. Suspect biliary atresia in babies with a persistent jaundice, lasting more than 14 days in term babies and 21 days in premature babies.
Initial investigation for possible biliary atresia
conjugated and unconjugated bilirubin. A high proportion of conjugated bilirubin suggests the liver is processing the bilirubin for excretion (by conjugating it), but it is not able to excrete the conjugated bilirubin because it cannot flow through the biliary duct into the bowel.
Management of biliary atresia
biliary atresia deifntion and pathophysiology
Causes of intestinal obstruction
Presentation of intestinal obstruction
intestinal obstruction investigations and results
abdominal xray.
dilated loops of bowel proximal to the obstruction and collapsed loops of bowel distal to the obstruction.
absence of air in the rectum.
management of intestinal obstruction
The key pathophysiology in Hirschsprung’s disease is
absence of parasympathetic ganglion cells in the distal bowel and rectum
It is responsible for stimulating peristalsis of the large bowel. Without this stimulation the bowel looses its motility and stops being able to pass food along its length
When the entire colon is affected in Hirschsprung’s this is called
Genetics and syndromes associated with Hirschsprung’s
Hirschsprung’s presentation
Hirschsprung-associated enterocolitis (HAEC) presentation, treatment and consequences if left untreated
Hirschsprung’s investigations and results
Abdominal xray can be helpful in diagnosing intestinal obstruction and demonstrating features of HAEC.
Rectal biopsy is used to confirm the diagnosis. The bowel histology will demonstrates an absence of ganglionic cells.
Hirschsprung’s management including management of complications
Unwell children and those with enterocolitis will require initial fluid resuscitation and management of the intestinal obstruction. IV antibiotics are required in HAEC.
Definitive management is by surgical removal of the aganglionic section of bowel.
Wilm’s tumour typical age presentation
children under 5 years of age, with a median age of 3 years old.
Wilm’s tumour associated syndromes and genetic mutations
- Beckwith-Wiedemann syndrome
- part of WAGR syndrome with Aniridia, Genitourinary malformations, mental Retardation
- hemihypertrophy
- around one-third of cases are associated with a loss-of-function mutation in the WT1 gene on chromosome 11
Wilm’s tumour features
Wilm’s tumour referral process
children with an unexplained enlarged abdominal mass in children - possible Wilm’s tumour - arrange paediatric review with 48 hours
Wilm’s tumour management
nephrectomy
chemotherapy
radiotherapy if advanced disease
prognosis: good, 80% cure rate
Volvulus definition and what it leads to
volvulus risks
- sigmoid volvulus: large bowel obstruction (large, dilated loop of colon, often with air-fluid levels)
- caecal volvulus: small bowel obstruction may be seen
Volvulus types, associations and patient groups it affects for each type
Risk factors for volvulus
Volvulus presentation
Volvulus investigations and findings
Volvulus management
Cow’s protein milk allergy risk factors
formula fed babies and those with a personal or family history of other atopic conditions.
Cow’s protein milk allergy presentation
Cow’s protein milk allergy management
Cow’s milk protein allergy vs Cow’s milk intolerance
Cow’s milk protein allergy differentials
Hernia definition, including inguinal hernia
Which type of inguinal hernia is most common in children
indirect
Pathophysiology of inguinal hernias: direct and indirect
Hesselbach’s triangle boundaries
Hesselbach’s triangle boundaries (RIP mnemonic):
R – Rectus abdominis muscle – medial border
I – Inferior epigastric vessels – superior / lateral border
P – Poupart’s ligament (inguinal ligament) – inferior border
Risk factors of inguinal hernias in children
Prematurity
Male sex (male:female ratio is approximately 8:1)
Family history
Clinical features of inguinal hernias including symptoms, examination findings and associated complications
Inguinal hernia in children differential diagnosis
- Hydrocele: possible to ‘get above’ a hydrocele, transilluminates, non-tender
- Varicocele: scrotal heaviness, non-tender, ‘bag-of-worms’ sensation on palpation
Inguinal hernia in children investigations
Inguinal hernia in children management
Inguinal hernia in children complications
- Recurrence
- Strangulation
- Incarceration
- Bowel obstruction
Umbilical hernia in children management, most common in which group, presentation
Strangulated hernia definition
Strangulated hernia risk factors and aetiology
Strangulated hernias typically present with the following:
Strangulated hernia differential diagnosis
Strangulated hernia investigations
Strangulated hernia management
Exomphalos definition
In exomphalos (also known as an omphalocoele) the abdominal contents protrude through the anterior abdominal wall but are covered in an amniotic sac formed by amniotic membrane and peritoneum
Exomphalos is associated with which conditions
Beckwith-Wiedemann syndrome
Down’s syndrome
cardiac and kidney malformations
Exomphalos management
Exomphalos should have a gradual repair to prevent respiratory complications. Gastroschisis requires urgent correction
Gastroschisis definition and management
Gastroschisis describes a congenital defect in the anterior abdominal wall just lateral to the umbilical cord.
Management
* vaginal delivery may be attempted
* newborns should go to theatre as soon as possible after delivery, e.g. within 4 hours
Neuroblastoma definition, originates from which cells, which gene mutations is it associated with?
Neuroblastoma risk factors
more likely if the child has other neurocristopathies, such as:
Hirschsprung’s Disease
Congenital Central Hypoventilation Syndrome.
Neuroblastoma signs and symptoms
blueberry muffin rash
Neuroblastoma investigations
Neuroblastoma management
Neuroblastoma prognosis
infantile colic presentation
difference between infantile spasms and infantile colic
In infantile spasms the child will become distressed between spasms, whereas in colic the child will become distressed during the ‘spasms’
Bloody stool most common organisms
- E.coli
- amoebic dysentery: need hot, fresh stool sample to send to lab for culture
- Shigella
- salmonella
