Paeds gastro, infection and immunity Flashcards
What is the cause of GOR in babies?
Inappropriate relaxation of the LOS (functional immaturity)
By when does GOR usuallly resolve?
12m - if persistent, may be due to GORD
How is GOR diagnosed?
Clinical dx
24h 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 1y
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 1-2w, 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 blood-stained or green seek medical attention
At what age does pyloric stenosis present?
2-8w
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 some other 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 - which is the opposite biochemial picture)
What is the best investigation for pyloric stenosis?
USS - shows target lesion of >3mm thickness
ABG to guide Mx
How should pyloric stenosis be managed?
- IV slow fluid resus + 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
Remains distressed in between episodes
What should be considered if the colic is persistent?
Cow’s milk protein allergy or reflux
Try:
- 2w trial of hydrosylate formula followed by
- 2w 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 <3s-
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
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 of intususception, may be bile-stained or not
What are the signs of intussusception?
Abdo distention with sausage shaped mass in RUQ
Emptiness on palpation in RLQ (Dance’s sign)
Red-currant jelly stool (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?
Emergency
If stable:
- Fluid resus
- Enema: pneumatic, forces bowel to un-telescope, take XRs throughout
If unstable:
- Open surgery
- Remove non-viable bowel
What should be done if there is recurrent intussusception?
Ix for a lead point
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
2y
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
- In first few days of life, with obstruction + possible compromised blood supply –> abdo pain, billious vomiting, peritonism
What is the main sign of volvulus on abdo examination?
Scaphoid abdomen
How should volvulus be investigated?
- Upper GI contrast study (urgent) 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
Maintenance fluid:
0-10 kg = 100mls/kg
10-20kgs = 1000mls + 50ml/kg for each kg >10kg
20+ kg = 1500mls + 20 mls/kg for each kg >20kg
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 1-2d, must stop within 3d
Diarrhoea: 5-7d, must stop within 2w
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 7 symptoms of hypernatraemia
Mnemonic: f(ull) of salt
Flushing
Oedema
Fever
Seizures
Agitation
Low urine output
Thirst
Recall 8 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, HF)
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 Na conc + 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 indicated even when cause is bacterial
Use when:
- SEPSIS
- salmonella < 6m
- 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 inc. iron, folate + B12
- Faecal calprotectin
- Colonoscopy + biopsy (cobblestones)
How should Crohn’s be treated?
Induce remission:
- Nutritional Mx
- replace diet with whole protein modular diet - excessively liquid, for 6-8w.
The products are easily-digested + replace lost weight
- Pharmacological Mx: steroids (prednisolone)
What is the classical presentation of UC?
Rectal bleeding
Diarrhoea
Abdo pain
What are the appropriate investigations to do in ulcerative colitis?
- FBC inc. 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 2 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 2w)
Step 2: maintain for 6m
Recall some important things to remember in PACES counselling for constipation
Explain movicol takes some time to work (dose increases over 2w)
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
Recall 2 risk factors for Hirschprung’s
Down’s
Men2a
Recall 2 signs and symptoms of Hirschprung’s
Failure to pass meconium in first 24h
Explosive passage of liquid/ foul stools
If Hirschprung’s doesn’t present in first few days of life, what may happen?
May present in 1-2w 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 dx is via suction-assisted full-thickness rectal biopsy showing absence of ganglion cells
What is the management of Hirschprungs?
1st line: bowel irrigation
Also 1st line - endorectal pullthrough (colostomy followed by anastomosing normally innervated bowel
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 2w
Recall all the principles of management for threadworm
Single dose of an anti-helminth (mebendazole) for the whole household
Advise rigorous hygeine for 2w if on mebendazole, or 6w if using hygeine measures alone
Exclusion from school/ nursery is not required
Give 4 causes of 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?
Clinical dx
- trial a 2w LF diet + review Sx
- 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 and vit D supplements
Digestive ensymes 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?
8-24months 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 and blood smear to look for anaemia
In older children/ adults: OJD and biopsy can confirm diagnosis
In younger children there is no histopathological confirmation
How should coeliac disease be managed?
Cut out all wheat, rye and barley
Dietician referral and 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