Paeds - Gastroenterology (Medical) Flashcards
Abdominal Pain in Children
Red Flags Symptoms for Serious Abdominal Pain
Differentials for Abdominal Pain
Recurrent/Functional Abdominal Pain
Abdominal Migraines
1.) Red Flags Symptoms for Serious Abdominal Pain
- persistent or bilious vomiting, abdo tenderness
- severe chronic diarrhoea, rectal bleeding
- fever, pain at night, dysphagia, failure to thrive
2.) Differentials for Abdominal Pain
- constipation, abdominal migraine, infantile colic,
- mesenteric adenitis, IBD, IBS, Coeliacs’, DKA
- UTI/pyelo, tonsillitis, Henoch-Schonlein purpura
- girls: dysmenorrhea, mittelschmerz, ectopic, PID, ovarian torsion, pregnancy
- surgical: appendicitis, intussusception, bowel obstruction, testicular torsion
- recurrent abdominal pain (diagnosis of exclusion)
3.) Recurrent/Functional Abdominal Pain - repeated abdo pain w/o an identifiable underlying cause
- often corresponds to stressful life events e.g. loss of a relative or bullying
- Mx: careful explanation and reassurance, lifestyle advice, probiotics, avoid NSAIDs, address psychosocial triggers and exacerbating factors, psychologists
4.) Abdominal Migraines - central abdo pain lasting >1hr with a normal examination +/- associated sx: N+V, photophobia, aura, headache, pallor, anorexia
- acute Tx: low stimulus environment, paracetamol, ibuprofen, sumatriptan
- preventative Tx: Pizotifen (main), Cyproheptadine, Propranolol, Flunarizine
Constipation in Children
Clinical Features
Red Flags for Constipation
Differentials
Management
1.) Clinical Features
- ↓frequency (<3/wk), type 1/2 stools, abdominal pain, palpable stools, PR bleed, ↓sensation to open bowels
- hard stools: difficult/straining/painful stool passage
- retentive posturing: holding an abnormal posture
- rectal bleeding: on wiping or mixed with stools
- encopresis (faecal incontinence): pathological >4yrs, a sign of chronic constipation, rectum stretches and loses sensation, faecal impaction leads to overflow soiling
2.) Red Flags for Constipation - need specialist referral
- delayed passage of meconium: CF, Hirschsprung’s
- neuro sx (esp lower limb): cerebral palsy, SC lesion
- vomiting: intestinal obstruction or Hirschsprung’s
- failure to thrive: coeliacs, hypothyroidism
- abnormal anus: (anal stenosis, IBD, sexual abuse)
- abnormal lower back or buttocks: spina bifida, sacral agenesis, spinal cord lesion
3.) Differentials
- functional constipation is the most common cause
- intestinal obstruction, CF, Hirschsprung’s disease
- cows milk protein allergy, hypothyroidism, SC lesion
- anal stenosis, sexual abuse
4.) General Management - clinical diagnosis
- lifestyle: high fibre diet, good hydration, exercise
- behavioural: scheduled toileting, bowel habit diary (track frequency and consistency), encouragement and reward systems for good toileting behaviour
- health visitor: offer support and encouragement to families from birth to primary school
5.) Laxatives - osmotic laxatives
- macrogol laxatives: 1°Movicol (Laxido, Cosmocol),
- faecal impaction requires high doses for disimpaction
- laxatives are continued long term and slowly weaned off as the child develops a normal, regular bowel habit
- complications: pain, fissures/haemorrhoids, reduced sensation and soiling, psychosocial morbidity
Gastro-Oesophageal Reflux (Disease)
Pathophysiology
Clinical Features
Differential Diagnosis
Management
1.) Pathophysiology - ↓tone of LOS –> uncontrolled reflux of stomach contents into the oesophagus
- regurgitation is when food is spat out (40% of infants)
- benign reflux: onset <6mths, lasting < 1 year
- very common in infants due to: shorter LOS and oesophagus, delayed gastric emptying, liquid diet causing stomach distension, lying down
- risk factors: prematurity, hiatal hernia, obesity, hx of diaphragmatic hernia or oesophageal atresia, parental hx of GORD, neuro disability (C.palsy)
2.) Clinical Features - sx to differentiate from normal reflux/regurgitation of feeds:
- distressed behaviour, unexplained feeding difficulties
- hoarseness, chronic cough (children), pneumonia
- report of retrosternal or epigastric pain (children)
- feeding hx: relation to feeds, position, attachment, technique, duration, frequency and type of milk, the volume of milk, the estimated volume of vomits
- general physical examination including hydration status, signs of malnutrition, growth charts
3.) Differential Diagnosis - vomiting
- overfeeding, pyloric stenosis, GI obstruction/bleed
- infection: gastroenteritis/gastritis, UTI, appendicitis, tonsillitis, meningitis, sepsis
- chronic diarrhoea, cow’s milk protein allergy
4.) Management
- effortless regurgitation requires no intervention
- frequent regurgitation causing marked distress in breastfed babies can be managed w/ antacids
- if formula-fed: avoid overfeeding (<150ml/kg/day), reduce volume and increase frequency
- 1°feed-thickener: trial for 2 weeks
- 2°alginate (antacid/Gaviscon): trial for 2 weeks
- 3°PPI or H2 antagonist for a 4-week trial
Infective Gastroenteritis
Pathophysiology
Clinical Features
Investigations
Complications
1.) Pathophysiology - enteric infection, most commonly viral but can also be bacterial or parasitic
- viral: rotavirus (infants), norovirus, adenovirus
- bacterial: campylobacter (most common), E.coli
2.) Clinical Features - clinical diagnosis
- sudden onset of loose/watery stool +/- vomiting
- mild fever, abdo pain/cramps
- recent contact w/ someone w/ diarrhoea or vomiting
- dehydration esp in children at increased risk:
- <6mths, >5 diarrhoeal stools OR >2x vomiting in the last 24hrs, stopped breastfeeding during the illness
3.) Investigations - not routinely required
- stool sample for investigations only if: suspected sepsis, blood/mucus in stool, immunocompromised
- blood tests (U+Es and glucose) only if: usage of IV fluids, sx of hypernatraemia, suspected shock
4.) Complications
- diarrhoea lasts 5-7 days, majority stop within 2 wks
- vomiting lasts 1-2 days, majority stop within 3 days
- haemolytic uraemic syndrome (HUS)
- toxic megacolon: a complication of rotavirus
- reactive complications from bacterial infection inc:
- arthritis, carditis, urticaria, erythema nodosum and conjunctivitis, Reiter’s syn…(uveitis/urethritis/arthritis)
- secondary lactose intolerance: improves when the infection resolves and the gut lining heals
Management of Gastroenteritis and Dehydration
No Clinical Dehydration
Clinical Assessment of Dehydration
Managing Dehydration
Management of Shock
1.) No Clinical Dehydration
- encourage fluid intake, continue milk feeding
- discourage fruit juices and carbonated drinks
- offer oral rehydration salt solution (ORS) as supplemental fluid to those at risk of dehydration
- do not use antidiarrhoeals in children <5yrs old
- avoid antibiotics and antidiarrhoeals because their use can trigger haemolytic uraemic syndrome
2.) Clinical Assessment of Dehydration
- RED FLAGS: appears unwell/deteriorating, altered responsiveness, sunken eyes, ↓skin turgor, ↑RR, ↑HR
- other sx: ↓urine output, dry mucous membranes
- hypernatremic dehydration: jittery movements, ↑tone,
hyperreflexia, convulsions, drowsiness or coma
- signs of shock: ↓consciousness, pale/mottled skin, cold extremities, ↑RR, ↑HR, weak pulses, ↑CRT
- signs of late (decompensated) shock: hypotension, ↓HR, acidosis, blue extremities, absent urine output
3.) Managing Dehydration
- ORS (Dioralyte): 50ml/kg over 4 hours to replace deficit plus maintenance fluid: 0-10kg = 100ml/kg, 10-20 = 50ml/kg, 20+ = 20ml/kg, total gives requirement over 24 hours
- give ORS frequently in small amounts, consider supplementation with their usual fluids
- NG tube if the child is refusing the oral fluid
- IV rehydration: suspected shock, any red flag sx, dehydration despite ORS, vomiting w/ PO or NG tube
4.) Management of Shock
- IV/IO 0.9% NaCl bolus of 20ml/kg over 10 minutes (10-20ml/kg in neonates), 10ml/kg in DKA to prevent cerebral oedema
- bolus can be repeated if still in shock, if considering the third bolus, consider calling ITU/anaesthetist
- once stable start maintenance fluids
Cow’s Milk Protein Allergy (CMPA)
Pathophysiology
Allergy Focused History
Clinical Features of IgE-Mediated CMPA
Clinical Features of Non-IgE-Mediated CMPA
Differential Diagnoses
1.) Pathophysiology - immune-mediated response to naturally-occurring milk proteins casein and whey
- IgE-mediated: type-I hypersensitivity reaction, IgE abs against the proteins trigger the release of histamine and other cytokines from mast cells and basophils
- non-IgE: T cell activation against cow’s milk protein
- risk factors: personal or FH of atopy, bottle-feeding
2.) Allergy Focused History
- age of onset, speed of onset after exposure, duration, severity and frequency, reproducibility of symptoms
- feeding and diet hx (inc mother’s diet if breastfed)
- atopy: asthma, eczema, hayfever, other allergies
- any previous management used for symptoms
3.) Clinical Features of IgE-Mediated CMPA
- rapid onset of symptoms
- GI: colicky abdo pain, N+V, diarrhoea
- skin reactions: pruritus, erythema, acute urticaria, acute angioedema (lips, face, around eyes)
- resp: LRT sx (cough, chest tightness wheeze, SOB) and URT sx (sneezing, rhinorrhoea, congestion)
4.) Clinical Features of Non-IgE-Mediated CMPA
- delayed onset: up to 48hrs or 1wk after ingestion
- GI: abdo pain, constipation, GORD, infantile colic
- diarrhoea, blood/mucus in stools, perianal redness
- food refusal, failure to thrive, pallor and tiredness
- skin reactions: pruritus, erythema, atopic eczema
- resp: LRT symptoms only
5.) Differential Diagnoses
- GORDs, IBD, Coeliac’s, constipation, gastroenteritis
- food intolerance (eg. lactose intolerance)
- allergic reaction to other food or non-food allergens
- pancreatic insufficiency, UTIs, Meckel’s diverticulum
Management of Cow’s Milk Protein Allergy
Investigations
Management
Complications
1.) Investigations - only if the diagnosis is unclear
- RAST test looking for specific IgE antibodies to cow’s milk protein, indications for testing include:
- faltering growth
- clinical diagnosis of non-IgE mediated CMPA
- confirmed IgE food allergy w/ asthma, suspicion of multiple food allergies esp w/ significant eczema
- 1+ acute systemic or severe delayed reactions
- other blood tests: FBC w/ haematinics
2.) Management
- avoidance of all forms of cow’s milk, including in the mother’s diet if she is breastfeeding
- elimination diet is required for at least 6 mths or the infant is 9-12mths, w/ re-evaluation of the infant every 6-12mths to assess for tolerance to cow’s milk protein
- replace milk with a hypoallergenic formula, 2 types:
- 1°extensively hydrolysed formula: casein and whey are broken down, cheaper, the majority respond (90%)
- 2°amino acid formula: more expensive, backup
- soya-based formulas are not for infants <6mths old
3.) Complications
- malabsorption or reduced intake leading to chronic iron-deficiency anaemia and faltering growth
- most patients will be milk tolerant by early childhood
- anaphylaxis is rare
Coeliac’s Disease
Pathophysiology
Gastrointestinal Features
Extra-Intestinal Features
Differential Diagnoses
1.) Pathophysiology - T cell-mediated immune reaction to the gliadin fraction of gluten causes damage to the villi in the small intestine which causes malabsorption
- antibodies are anti-TTG and anti-EMA (both IgA)
- associated w/ other autoimmune conditions: T1 DM, thyroid disease, autoimmune hepatitis, PBC, PSC
- also associated with Turner’s and Down syndrome
- can present in at any age (early childhood common)
2.) Gastrointestinal Features - classical form, presents from 9-24mths of ages w/ features of malabsorption:
- diarrhoea, steatorrhoea (foul smelling)
- abdominal pain and distension/bloating
- failure to thrive, weight loss/anorexia, muscle wasting (often buttocks)
3.) Extra-Intestinal Features - atypical form
- dermatitis herpetiformis (itchy skin rash on abdomen): treat with topical dapsone
- anaemia (↓iron/B12/folate), osteoporosis (↓Vit D)
- neuro: peripheral neuropathy, epilepsy, ataxia
- short stature, delayed puberty, infertility
- functional hyposplenism: ↑risk of infections
- arthritis, liver and biliary tract disease
- poor control/gluten diet can lead to the development of enteropathy T-cell lymphoma (non-Hodgkin’s Lymphoma)
4.) Differential Diagnosis
- cystic fibrosis, IBD, post-gastroenteritis, autoimmune enteropathy, eosinophilic enteritis, tropical sprue
Management of Coeliac Disease
Criteria for Serological Investigation
Investigations
Management
1.) Criteria for Serological Investigation
- persistent unexplained abdominal or GI symptoms
- faltering growth, prolonged fatigue, unexpected weight loss, severe or persistent mouth ulcers
- unexplained iron, vitamin B12 or folate deficiency
- at diagnosis of T1 diabetes, autoimmune thyroid disease, IBS in adults
- first‑degree relatives of people with coeliac disease
2.) Investigations - serology is only accurate if gluten has been in the diet for at least 6wks before testing
- test for total IgA and anti-tTG, if anti-tTG is weakly positive OR total IgA is deficient, use anti-EMA
- if serology is +ve, endoscopic intestinal/duodenal biopsy is carried out which should show ↑inflammatory cells, crypt hyperplasia, villous atrophy (severe)
3.) Management - a lifelong diet free of gluten
- gluten-free diet: avoid wheat, barley, rye, oats
- diet supplements if obvious malabsorption e.g. iron
- annual follow up to check for sx, diet compliance, development, growth and long term complications
- anti-TTG can be monitored to check compliance
- pneumococcal vaccination every 5 years
Crohn’s Disease (IBD)
Risk Factors
Clinical Features
Investigations
Imaging
1.) Risk Factors
- age (15-30/60-80), smoking, FH of IBD
- white European, appendicectomy
2.) Clinical Features - episodic abdominal pain and chronic diarrhoea which may contain blood or mucus
- pain can be anywhere but is most common in RLQ
- malaise, malabsorption, weight loss
- oral aphthous ulcers, perianal disease
- extra-intestinal features
3.) Investigations
- routine bloods: anaemia, low albumin, inflammation
- stool sample, faecal calprotectin
- proctosigmoidoscopy for perianal fistulae
4.) Imaging
- colonoscopy: skip lesions, ‘cobblestone’ appearance
- histology: ↑goblet cells, non-caseating granulomas
- CT-AP: for bowel obstruction, perforation, fistulae
- MRI: MREnterography for SI involvement and enteric fistulae, MRI-Rectum for peri-anal disease
Management and Complications of Crohn’s Disease
Inducing Remission
Maintaining Remission
Surgical Intervention
GI Complications
Extraintestinal Complications
1.) Inducing Remission - for acute attacks
- IV fluids (resus), nutritional support
- prophylactic heparin (IBD is pro-thrombotic)
- IV hydrocortisone 100mg QDS for 3-5d (very unwell)
- steroids also given topically (enemas) or orally (pred)
2.) Maintaining Remission
- azathioprine
- biologics (infliximab, first line for perianal or fistulating Crohn’s)
- rescue therapy: biologics or surgery
3.) Surgical Intervention - often bowel resections
- reasons: failed medical management, severe complications, growth impairment in children
4.) GI Complications
- fistulas, strictures, recurrent perianal abscesses
- GI malignancy: colorectal cancer, small bowel cancer
5.) Extraintestinal Complications - due to malabsorption
- growth delay in children, osteoporosis
- ↑risk of gallstones and renal stones
Ulcerative Colitis (IBD)
Risk Factors
Clinical Features
Investigations
Imaging
1.) Risk Factors
- age (15-25/55-65), FH of IBD
- smoking is a protective factor (reduces risk)
2.) Clinical Features - bloody diarrhoea
- change in bowel habits: PR bleed, mucus discharge, ↑frequency, urgency of defecation, tenesmus
- dehydration, malaise, low-grade fever, anorexia
- abdominal pain for complications: toxic megacolon, perforation, fulminant colitis, peritonitis
3.) Investigations
- routine bloods: anaemia, low albumin, inflammation
- LFTs deranged in patients on medical treatment
- clotting can be deranged in severe attacks
- stool sample, faecal calprotectin
4.) Imaging
- colonoscopy (gold): continuous, pseudopolypoid
- histology: ↓goblet cells, crypt abscesses
- flexible sigmoidoscopy may be sufficient
- acute exacerbations: AXR (thumbprinting) or CT for complications
- AXR to rule out toxic megacolon
Management and Complications of Ulcerative Colitis
Induce Remission
Maintain Remission
Surgical Intervention
Complications
1.) Induce Remission - for acute attacks
- severity: mild = <4 bloody stools/day, moderate: 4-6 bloody stools/day, severe: 6+ inc systemic sx
- mild-mod: PR mesalazine (4wks) –> add PO mesalazine –> topical or PO prednisolone
- severe: IV hydrocortisone 100mg QDS for 3-5d
- IV fluids (resus), nutritional support
- prophylactic heparin (IBD is pro-thrombotic)
2.) Maintain Remission
- PR +/- PO mesalazine (aminosalicylate) is first line
- azathioprine or biologics if mesalazine ineffective
- rescue therapy: cyclosporin, biologics, surgery
3.) Surgical Intervention - often bowel resections
- reasons: failed medical management, toxic megacolon, bowel perforation, ↓risk of carcinoma
- total proctocolectomy is curative
4.) Complications
- toxic megacolon: severe abdo pain and distension, w/ pyrexia and systemic toxicity need decompression
- colorectal carcinoma: undergoing screening 10yrs from diagnosis
- osteoporosis
- pouchitis: inflammation of ileal pouch
