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Finals Systems > Paeds gastroenterology > Flashcards

Paeds gastroenterology Flashcards

1
Q

Investigation - pyloric stenosis

A

Ultrasound to visualise thickened pylorus

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2
Q

Blood gas pyloric stenosis

A

Hypochloric, hypokalaemic metabolic alkalosis

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3
Q

Management pyloric stenosis

A

laparoscopic pyloromyotomy

known as Ramstedt’s pyloromyotomy

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4
Q

What type of jaundice causes dark urine and pale stools

A

In obstructive jaundice (both intrahepatic cholestasis and extrahepatic obstruction) the serum bilirubin is principally conjugated. Conjugated bilirubin is water soluble and is excreted in the urine, giving it a dark colour (bilirubinuria).

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5
Q

target like mass abdo scan

A

intussception

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6
Q

acute cyclical colicky abdominal pain and ‘currant jelly” stools. It may also present with vomiting, which in later stages may become bilious, but this is a rare and late feature

A

intussception

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7
Q

A 9-day-old pre-term neonate stops tolerating his cow’s milk feeds given by the nurses in the special care baby unit. He vomited after the most recent feed and the nurse noticed bile in the vomit. Stools are normal consistency but the last stool contained fresh red blood. On examination he is well hydrated but his abdomen is grossly distended and an urgent abdominal x-ray is requested. X-ray shows distended loops of bowel with thickening of the bowel wall

A

NEC

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8
Q

A father brings his 16-day old baby presents to the emergency department. The baby is visibly jaundiced and distressed, and the father explains the baby has not been feeding well since yesterday. Examination reveals hepatomegaly and splenomegaly. A newborn jaundice screen indicates no infection, normal thyroid function tests, raised conjugated bilirubin, liver transaminases and bile acids. The urine is negative for reducing substances

A

biliary atresia

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9
Q

a baby with a history of untreated prolonged jaundice becomes less responsive, floppy, drowsy, poor feeding

A

kernicterus

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10
Q

Travellers diarrhoea
Develops 2 to 5 days after:
Raw or improperly cooked poultry
Untreated water
Unpasteurised milk

Abdominal cramps
Diarrhoea often with blood
Vomiting
Fever

A

Cambylobacter jejuni

Abx if rf such as heart failure or HIV:

azithromycin or ciprofloxacin

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11
Q

Gastroenteritis 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.

A

Bacillus cereus

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12
Q

eating raw or undercooked pork can cause this infection. It is also spread through contamination with the urine or faeces of other mammal such as rats and rabbits.

watery or bloody diarrhoea, abdominal pain, fever and lymphadenopathy. Incubation is 4 to 7 days and the illness can last longer than other causes of enteritis with symptoms lasting 3 weeks or more.

A

Yersinia Enterocolitica

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13
Q

Infection may not cause any symptoms, or it may cause chronic diarrhoea.

A

Giardiasis

Metronidazole

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14
Q

Gastroenteritis spread through contact with infected faeces, unwashed salads or contaminated water.

A

E.coli 0157

Shigella

Both produce shiga toxin which can cause haemolytic uraemic syndrome

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15
Q

Gastroenteritis spread by eating raw eggs or poultry, or food contaminated with the infected faeces of small animals.

A

Salmonella

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16
Q

A 39 hour old neonate is brought to their GP by their parents. The child has not passed stool since being birthed at home and has started vomiting yellow/green liquid after feeding. On examination the childs stomach is grossly distended but with no palpable masses.

A

hirschsprung’s disease

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17
Q

2-4 weeks of birth with fever, abdominal distention, diarrhoea (often with blood) and features of sepsis.

A

Hirschsprung-Associated Enterocolitis

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18
Q

A 4-day-old girl who was diagnosed prenatally with Down’s syndrome and born at 38 weeks gestation presents with bilious vomiting and abdominal distension. She is yet to pass meconium.

A

hirchsprungs disease

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19
Q

A 5-week-old infant is brought into the emergency department by his mother with vomiting after every feed. The vomit is non-bilious, large volume and projectile. His mother reports this was initially small amounts of vomit and infrequent, but has increased in volume and regularity over the past week. The infant appears keen to try feeding again after each vomiting episode

A

pyloric stenosis

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20
Q

“Diarrhoea usually non-bloody, Weight loss more prominent, Upper gastrointestinal symptoms, mouth ulcers, perianal disease, Abdominal mass palpable in the right iliac fossa”

A

crohns

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21
Q

“Bloody diarrhoea more common, Abdominal pain in the left lower quadrant, Tenesmus”

A

ulcerative colitis

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22
Q

“abdo pain relieved by defecation, change in bowel habit, bloating, mucus”

A

IBS

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23
Q

Management idiopathic constipation

A
  1. Movicol paediatric plain
  2. Add stimulant laxative eg senna
  3. Add lactulose or docusate if stools are hard
    ​​4. Continue medication at maintenance dose for several weeks after regular bowel habit is established, then reduce the dose gradually
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24
Q

Management GORD paeds

A
  1. a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum)
  2. a trial of alginate therapy e.g. Gaviscon. Alginates should not be used at the same time as thickening agents
  3. PPI if unexplained feeding difficulties (for example, refusing feeds, gagging or choking)
    distressed behaviour
    faltering growth
  4. prokinetic agents e.g. metoclopramide should only be used with specialist advice
  5. If there are severe complications (e.g. failure to thrive) and medical treatment is ineffective then fundoplication may be considered
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25
Q

Sandifer’s Syndrome

A

This is a rare condition causing brief episodes of abnormal movements associated with gastro-oesophageal reflux in infants. The infants are usually neurologically normal. The key features are:

Torticollis: forceful contraction of the neck muscles causing twisting of the neck
Dystonia: abnormal muscle contractions causing twisting movements, arching of the back or unusual postures

The condition tends to resolve as the reflux is treated or improves.

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26
Q

Investigation and management pyloric stenosis

A

USS to visualise thickened pylorus

laparoscopic pyloromyotomy - known as “Ramstedt’s operation

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27
Q

GORD investigation if severe

A

24 hour oesophageal pH monitoring

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28
Q

Associations hirschsprungs disease

A

3 times more common in males
Down’s syndrome

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29
Q

“failure to pass meconium, constipation since birth, failure to thrive, vomiting, abdominal distension, failure to thrive”

A

hirschsprungs disease

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30
Q

“reflux of feeds, non-bilious” “refusing feeds, distress, pneumonia”

A

GORD

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31
Q

A 2-year-old child has a history of chronic constipation for the past year and chronic abdominal distention with vomiting for three months.

A

hirschsprungs

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32
Q

Investigations for hirschsprungs disease

A

abdominal x-ray (A plain abdominal x ray will demonstrate dilated loops of bowel with fluid levels and a barium enema can be helpful when it demonstrates a cone with dilated ganglionic proximal colon and the distal aganglionic bowel failing to distend.)

rectal biopsy: gold standard for diagnosis (The bowel histology will demonstrate an absence of ganglionic cells.)

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33
Q

management hirschsprungs disease

A

initially: rectal washouts/bowel irrigation
definitive management: surgery to affected segment of the colon

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34
Q

Hirschsprung-associated enterocolitis

A

Hirschsprung-associated enterocolitis (HAEC) is inflammation and obstruction of the intestine occurring in around 20% of neonates with Hirschsprung’s disease. It typically presents within 2-4 weeks of birth with fever, abdominal distention, diarrhoea (often with blood) and features of sepsis. It is life threatening and can lead to toxic megacolon and perforation of the bowel. It requires urgent antibiotics, fluid resuscitation and decompression of the obstructed bowel.

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35
Q

management meconium ileus

A
  1. PR contrast studies may dislodge meconium plugs and be therapeutic
  2. NG N-acetylcystine
  3. surgery
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36
Q

“failure to mass meconium, abdo distension, may or may not have obstructive symptoms”

A

meconium ileus

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37
Q

(6-18 months) “bouts of inconsolable crying, drawing knees up, colicky pain, bilious vomiting, red currant jelly stool, sausage shaped mass in RUQ”

A

intussception

38
Q

investigations intussception

A

abdo ultrasound

39
Q

coffee bean sign on abdo xray

A

volvulus

40
Q

management intussception

A

the majority of children can be treated with reduction by air insufflation under radiological control, which is now widely used first-line compared to the traditional barium enema

if this fails, or the child has signs of peritonitis, surgery is performed

41
Q

XR double bubble

A

duodenal atresia

42
Q

“child with downs syndrome has vomiting in first days of life after they start feeding”

A

duodenal atresia

43
Q

Investigations duodenal atresia

A

AXR shows double bubble sign, contrast study may confirm

44
Q

association with duodenal atresia

A

down’s

45
Q

management of duodenal atresia

A

duodenoduodenostomy

46
Q

XR air fluid levels

A

jejunal atresia

47
Q

jejunal atresia management?

A

Laparotomy with primary resection and anastomosis

48
Q

“a premature neonate in second week of life has bilious vomiting, not tolerating feeds, distended abdomen, blood in stools”

A

NEC

49
Q

Investigation of choice NEC

A

Abdominal x ray

50
Q

Xr NEC will show?

A

Dilated loops of bowel
Bowel wall oedema (thickened bowel walls)
Pneumatosis intestinalis is gas in the bowel wall and is a sign of NEC

51
Q

Management NEC

A

step 1: nil by mouth with IV fluids, total parenteral nutrition (TPN) and antibiotics to stabilise them

step 2 : A nasogastric tube can be inserted to drain fluid and gas from the stomach and intestines.

step 3: surgery

52
Q

what is meckels diverticulum a remenant of?

A

omphalomesenteric duct

53
Q

“2 years of age, massive rectal bleeding, painless or pain mimicking appendicitis”

A

meckels diverticulum

54
Q

Investigation of meckels diverticulum

A

technetium scan if haemodynamically stable with less severe or intermittent bleeding then a ‘Meckel’s scan’ should be considered - uses 99m technetium pertechnetate, which has an affinity for gastric mucosa

mesenteric arteriography may also be used in more severe cases e.g. transfusion is required

55
Q

management of meckels diverticulum

A

removal if narrow neck or symptomatic
options are between wedge excision or formal small bowel resection and anastomosis

56
Q

“bilious vomiting, distended abdomen, absent bowel sounds, absolute constipation”

A

intestinal malrotation with volvulus

57
Q

Invetsigation and management intestinal malrotation

A

Diagnosis is made by upper GI contrast study and USS

Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a Ladd’s procedure is performed (includes division of Ladd bands and widening of the base of the mesentery)

58
Q

Differentiating intussception and malrotation

A

Intussusception is a condition commonly defined as telescoping bowel. This condition causes ischaemia of the affected bowel segment, leading to acute cyclical colicky abdominal pain and ‘currant jelly” stools. It may also present with vomiting, which in later stages may become bilious, but this is a rare and late feature, rather than being the presenting feature as in this case.

59
Q

Diagnosis of appendicitis

A

Diagnosis is based on the clinical presentation and raised inflammatory markers.

Performing a CT scan can be useful in confirming the diagnosis, particularly where another diagnosis is more likely. An ultrasound scan is often used in female patients to exclude ovarian and gynaecological pathology.

60
Q

acute, perisstent and chronic diarrhoea

A

Acute (≤14 days)
Persistent (>14 days), or
Chronic (>4 weeks).

61
Q

Common causes viral gastroenteritis

A

Rotavirus
Norovirus

62
Q

“1-5 year old, frequent diarrhoea - the stools are foul smelling, watery, and contain mucus with undigested vegetable material. No failure to thrive”

A

Toddlers diarrhoea

63
Q

“chronic constipation, chronic abdominal distension, chronic vomiting”

A

Milder hirschsprung’s disease

64
Q

Features of crohn’s

A

Crohn’s (crows NESTS)
N – No blood or mucus (these are less common in Crohns.)
E – Entire GI tract
S – “Skip lesions” on endoscopy
T – Terminal ileum most affected and Transmural (full thickness) inflammation
S – Smoking is a risk factor (don’t set the nest on fire)
Crohn’s is also associated with weight loss, strictures and fistulas.

65
Q

Features of ulcerative colitis

A

Ulcerative Colitis (remember U – C – CLOSEUP)
C – Continuous inflammation
L – Limited to colon and rectum
O – Only superficial mucosa affected
S – Smoking is protective
E – Excrete blood and mucus
U – Use aminosalicylates
P – Primary sclerosing cholangitis

66
Q

Gold standard for diagnosing IBD

A

Endoscopy (OGD and colonoscopy) with biops

67
Q

screening test IBD

A

Faecal calprotectin is released by the intestines when inflamed. It is a useful screening test and is more than 90% sensitive and specific for IBD in adults.

68
Q

Management of crohn’s - inducing remission

A
  1. oral prednisolone or IV hydrocortisone

If unsuccessful, ask specialist about
Azathioprine
Mercaptopurine
Methotrexate
Infliximab
Adalimumab

69
Q

Management of crohn’s - maintaining remission

A

First line:
Azathioprine
Mercaptopurine

Alternatives:
Methotrexate
Infliximab
Adalimumab

70
Q

Management of UC- inducing remission

A

Mild to moderate disease
First line: aminosalicylate (e.g. mesalazine oral or rectal)
Second line: corticosteroids (e.g. prednisolone)

Severe disease
First line: IV corticosteroids (e.g. hydrocortisone)
Second line: IV ciclosporin

71
Q

Maintaining remission UC

A

Aminosalicylate (e.g. mesalazine oral or rectal)
Azathioprine
Mercaptopurine

72
Q

“Diarrhoea usually non-bloody, Weight loss more prominent, Upper gastrointestinal symptoms, mouth ulcers, perianal disease, Abdominal mass palpable in the right iliac fossa”

A

Crohns

73
Q

“Bloody diarrhoea more common, Abdominal pain in the left lower quadrant, Tenesmus”

A

UC

74
Q

“abdo pain relieved by defecation, change in bowel habit, bloating, mucus”

A

IBS

75
Q

“central abdo pain → RIF, vomiting, anorexia, tenderness”

A

appendicitis

76
Q

IBS drug management

A

Loperamide for diarrhoea

Laxatives for constipation. Avoid lactulose as it can cause bloating. Linaclotide is a specialist laxative for patients with IBS not responding to first-line laxatives

Antispasmodics for cramps e.g. hyoscine butylbromide (Buscopan)

77
Q

Genetic associations coeliac

A

HLA-DQ2 gene (90%)
HLA-DQ8 gene

78
Q

auto antibodies coeliac

A

Tissue transglutaminase antibodies (anti-TTG)
Endomysial antibodies (EMAs)
Deaminated gliadin peptides antibodies (anti-DGPs)

79
Q

what do you need to test alongside antibodies in coeliac

A

IgA incase deficienct

80
Q

“failure to thrive, rash, diarrhoea, bloated”

A

coeliac

81
Q

Endoscopy and intestinal biopsy results coeliac

A

“Crypt hypertrophy”
“Villous atrophy”

82
Q

coeliac associations

A

Type 1 diabetes
Thyroid disease
Autoimmune hepatitis
Primary biliary cirrhosis
Primary sclerosing cholangitis
Down’s syndrome

83
Q

pathophysiology cows milk protein intolerance/allergy

A

Both immediate (IgE mediated) and delayed (non-IgE mediated) reactions are seen. The term CMPA is usually used for immediate reactions and CMPI for mild-moderate delayed reactions.

84
Q

Diagnosis CMPA/I

A

Diagnosis is often clinical (e.g. improvement with cow’s milk protein elimination). Investigations include:
skin prick/patch testing
total IgE and specific IgE (RAST) for cow’s milk protein

85
Q

Management CMPA if formula fed

A
  1. extensively hydrolysed formula (eHF) milk is the first-line replacement formula for infants with mild-moderate symptoms
  2. amino acid-based formula (AAF) in infants with severe CMPA or if no response to eHF

around 10% of infants are also intolerant to soya milk

86
Q

management CMPA if breastfed

A

eliminate cow’s milk protein from maternal diet. Consider prescribing calcium supplements for breastfeeding mothers whose babies have, or are suspected to have, CMPI, to prevent deficiency whilst they exclude dairy from their diet

use eHF milk when breastfeeding stops, until 12 months of age and at least for 6 months

87
Q

Does CMPI/A resolve?

A

in children with IgE mediated intolerance around 55% will be milk tolerant by the age of 5 years
in children with non-IgE mediated intolerance most children will be milk tolerant by the age of 3 years
a challenge is often performed in the hospital setting as anaphylaxis can occur.

88
Q

when do you repair inguinal hernias

A

six/two rule:
< 6 weeks old = correct within 2 days
< 6 months = correct within 2 weeks
< 6 years = correct within 2 months

89
Q

Choledochal cysts

A

A choledochal cyst is a congenital anomaly of the duct (tube) that transports bile from the liver to the gall bladder and small intestine. The liver produces bile to help digest food. When a child has a choledochal cyst, a swelling of that duct, bile may back up in the liver.

90
Q

Investigation ovarian torsion

A

Pelvic ultrasound is the initial investigation of choice. Transvaginal is ideal, but transabdominal can be used where transvaginal is not possible.

91
Q

why no fluid levels in CF meconium ileus

A

Fluid levels are scarce as the meconium is viscid.

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