Paeds gastroenterology Flashcards
Investigation - pyloric stenosis
Ultrasound to visualise thickened pylorus
Blood gas pyloric stenosis
Hypochloric, hypokalaemic metabolic alkalosis
Management pyloric stenosis
laparoscopic pyloromyotomy
known as Ramstedt’s pyloromyotomy
What type of jaundice causes dark urine and pale stools
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).
target like mass abdo scan
intussception
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
intussception
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
NEC
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
biliary atresia
a baby with a history of untreated prolonged jaundice becomes less responsive, floppy, drowsy, poor feeding
kernicterus
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
Cambylobacter jejuni
Abx if rf such as heart failure or HIV:
azithromycin or ciprofloxacin
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.
Bacillus cereus
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.
Yersinia Enterocolitica
Infection may not cause any symptoms, or it may cause chronic diarrhoea.
Giardiasis
Metronidazole
Gastroenteritis spread through contact with infected faeces, unwashed salads or contaminated water.
E.coli 0157
Shigella
Both produce shiga toxin which can cause haemolytic uraemic syndrome
Gastroenteritis spread by eating raw eggs or poultry, or food contaminated with the infected faeces of small animals.
Salmonella
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.
hirschsprung’s disease
2-4 weeks of birth with fever, abdominal distention, diarrhoea (often with blood) and features of sepsis.
Hirschsprung-Associated Enterocolitis
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.
hirchsprungs disease
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
pyloric stenosis
“Diarrhoea usually non-bloody, Weight loss more prominent, Upper gastrointestinal symptoms, mouth ulcers, perianal disease, Abdominal mass palpable in the right iliac fossa”
crohns
“Bloody diarrhoea more common, Abdominal pain in the left lower quadrant, Tenesmus”
ulcerative colitis
“abdo pain relieved by defecation, change in bowel habit, bloating, mucus”
IBS
Management idiopathic constipation
- Movicol paediatric plain
- Add stimulant laxative eg senna
- 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
Management GORD paeds
- a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum)
- a trial of alginate therapy e.g. Gaviscon. Alginates should not be used at the same time as thickening agents
- PPI if unexplained feeding difficulties (for example, refusing feeds, gagging or choking)
distressed behaviour
faltering growth - prokinetic agents e.g. metoclopramide should only be used with specialist advice
- If there are severe complications (e.g. failure to thrive) and medical treatment is ineffective then fundoplication may be considered
Sandifer’s Syndrome
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.
Investigation and management pyloric stenosis
USS to visualise thickened pylorus
laparoscopic pyloromyotomy - known as “Ramstedt’s operation
GORD investigation if severe
24 hour oesophageal pH monitoring
Associations hirschsprungs disease
3 times more common in males
Down’s syndrome
“failure to pass meconium, constipation since birth, failure to thrive, vomiting, abdominal distension, failure to thrive”
hirschsprungs disease
“reflux of feeds, non-bilious” “refusing feeds, distress, pneumonia”
GORD
A 2-year-old child has a history of chronic constipation for the past year and chronic abdominal distention with vomiting for three months.
hirschsprungs
Investigations for hirschsprungs disease
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.)
management hirschsprungs disease
initially: rectal washouts/bowel irrigation
definitive management: surgery to affected segment of the colon
Hirschsprung-associated enterocolitis
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.
management meconium ileus
- PR contrast studies may dislodge meconium plugs and be therapeutic
- NG N-acetylcystine
- surgery
“failure to mass meconium, abdo distension, may or may not have obstructive symptoms”
meconium ileus
(6-18 months) “bouts of inconsolable crying, drawing knees up, colicky pain, bilious vomiting, red currant jelly stool, sausage shaped mass in RUQ”
intussception
investigations intussception
abdo ultrasound
coffee bean sign on abdo xray
volvulus
management intussception
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
XR double bubble
duodenal atresia
“child with downs syndrome has vomiting in first days of life after they start feeding”
duodenal atresia
Investigations duodenal atresia
AXR shows double bubble sign, contrast study may confirm
association with duodenal atresia
down’s
management of duodenal atresia
duodenoduodenostomy
XR air fluid levels
jejunal atresia
jejunal atresia management?
Laparotomy with primary resection and anastomosis
“a premature neonate in second week of life has bilious vomiting, not tolerating feeds, distended abdomen, blood in stools”
NEC
Investigation of choice NEC
Abdominal x ray
Xr NEC will show?
Dilated loops of bowel
Bowel wall oedema (thickened bowel walls)
Pneumatosis intestinalis is gas in the bowel wall and is a sign of NEC
Management NEC
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
what is meckels diverticulum a remenant of?
omphalomesenteric duct
“2 years of age, massive rectal bleeding, painless or pain mimicking appendicitis”
meckels diverticulum
Investigation of meckels diverticulum
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
management of meckels diverticulum
removal if narrow neck or symptomatic
options are between wedge excision or formal small bowel resection and anastomosis
“bilious vomiting, distended abdomen, absent bowel sounds, absolute constipation”
intestinal malrotation with volvulus
Invetsigation and management intestinal malrotation
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)
Differentiating intussception and malrotation
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.
Diagnosis of appendicitis
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.
acute, perisstent and chronic diarrhoea
Acute (≤14 days)
Persistent (>14 days), or
Chronic (>4 weeks).
Common causes viral gastroenteritis
Rotavirus
Norovirus
“1-5 year old, frequent diarrhoea - the stools are foul smelling, watery, and contain mucus with undigested vegetable material. No failure to thrive”
Toddlers diarrhoea
“chronic constipation, chronic abdominal distension, chronic vomiting”
Milder hirschsprung’s disease
Features of crohn’s
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.
Features of ulcerative colitis
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
Gold standard for diagnosing IBD
Endoscopy (OGD and colonoscopy) with biops
screening test IBD
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.
Management of crohn’s - inducing remission
- oral prednisolone or IV hydrocortisone
If unsuccessful, ask specialist about
Azathioprine
Mercaptopurine
Methotrexate
Infliximab
Adalimumab
Management of crohn’s - maintaining remission
First line:
Azathioprine
Mercaptopurine
Alternatives:
Methotrexate
Infliximab
Adalimumab
Management of UC- inducing remission
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
Maintaining remission UC
Aminosalicylate (e.g. mesalazine oral or rectal)
Azathioprine
Mercaptopurine
“Diarrhoea usually non-bloody, Weight loss more prominent, Upper gastrointestinal symptoms, mouth ulcers, perianal disease, Abdominal mass palpable in the right iliac fossa”
Crohns
“Bloody diarrhoea more common, Abdominal pain in the left lower quadrant, Tenesmus”
UC
“abdo pain relieved by defecation, change in bowel habit, bloating, mucus”
IBS
“central abdo pain → RIF, vomiting, anorexia, tenderness”
appendicitis
IBS drug management
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)
Genetic associations coeliac
HLA-DQ2 gene (90%)
HLA-DQ8 gene
auto antibodies coeliac
Tissue transglutaminase antibodies (anti-TTG)
Endomysial antibodies (EMAs)
Deaminated gliadin peptides antibodies (anti-DGPs)
what do you need to test alongside antibodies in coeliac
IgA incase deficienct
“failure to thrive, rash, diarrhoea, bloated”
coeliac
Endoscopy and intestinal biopsy results coeliac
“Crypt hypertrophy”
“Villous atrophy”
coeliac associations
Type 1 diabetes
Thyroid disease
Autoimmune hepatitis
Primary biliary cirrhosis
Primary sclerosing cholangitis
Down’s syndrome
pathophysiology cows milk protein intolerance/allergy
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.
Diagnosis CMPA/I
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
Management CMPA if formula fed
- extensively hydrolysed formula (eHF) milk is the first-line replacement formula for infants with mild-moderate symptoms
- 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
management CMPA if breastfed
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
Does CMPI/A resolve?
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.
when do you repair inguinal hernias
six/two rule:
< 6 weeks old = correct within 2 days
< 6 months = correct within 2 weeks
< 6 years = correct within 2 months
Choledochal cysts
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.
Investigation ovarian torsion
Pelvic ultrasound is the initial investigation of choice. Transvaginal is ideal, but transabdominal can be used where transvaginal is not possible.
why no fluid levels in CF meconium ileus
Fluid levels are scarce as the meconium is viscid.
