Paeds GI Flashcards
How is transient synovitis managed ?
- Simple analgesia
- Safety net to attend A&E if symptoms worsen or they develop a fever !
What are the symptoms of an appendicitis ?
- Umbilical pain that spreads to the RIF
- Anorexia
- N&V
What are the signs of an appendicitis ?
- > Tenderness and guarding over McBurney’s point
- > Rovsing’s sign : palpation in LIF causes pain in the RIF
- > Fever
- > Abdo pain aggravated my movement
Give 2 signs of peritonitis
- Rebound tenderness : increased pain following quick release of pressure of RIF
- Percussion tenderness
Give 3 complications of an appendicitis
- Rupture -> peritonitis
- Abscess
- Appendix mass
Define biliary atresia
- Section of the bile duct is either narrowed or absent
- This leads to cholestasis, where bile cannot be transported from the liver to the bowel
How does biliary atresia present
- Persistent jaundice shortly after birth
- Dark urine, pale stools
- Hepatosplenomegly
Define prolonged jaundice in term and premature babies
- Term : 14 days
- Premature : 21 days
What investigations are used in biliary atresia ?
Raised levels of conjugated bilirubin
- > There will be a high proportion of conjugated bilirubin (the liver can process it but not excrete it)
How is biliary atresia managed?
- > Kasai portoenterostomy : attaching a section of the small intestine to the opening of the liver where the bile duct normally attaches.
- > Often require a liver transplant in later life
Explain the pathophysiology behind coeliac disease
- Gliadin in gluten provokes a damaging immunological response in the proximal small intestinal mucosa
- > Anti-TTG and anti-EMA antibodies target epithelial cells and cause inflammation
How does coeliac disease present ?
- Failure to thrive
- Diarrhoea
- Fatigue
- Weight loss
- Mouth ulcers
- Iron an/or folate deficiency anaemia
- Growth failure
- Dermatitis herpetiformis
What bloods are done in coeliac disease ?
- First check IgA levels to exclude IgA deficiency
- Raised anti-TTG
- Raised anti-EMA
What is seen on an endoscopy + biopsy in coeliac disease ?
- Jejunum is most affected
- Crypt hypertrophy
- Villous atrophy
- Increased intraepithelial lymphocytes
Define crohns disease
-Transmural granulomatous chronic inflammation of the GI tract
How does crohns disease present ?
- Abdo pain, diarrhoea, weight loss
- Growth failure due to malabsorption
- Delayed puberty
What are the extraintestinal symptoms of crohns?
- Oral lesions or perianal skin tags
- Uveitis
- Arthralgia
- Erythema nodosum
What bloods are seen in crohns ?
- Raised faecal calprotectin
- Raised plts, ESR and CRP
- IDA due to malabsorption
- low serum albumin
What is seen on endoscopy + biopsy in crohns
- Skip lesions
- Non-caseating granulomas
- Transmural damage, terminal ileum most severe
How is remission induced in crohns ?
- Nutritional therapy for 6-8 wks
- Systemic steroids if necessary (oral pred, IV hydrocortisone)
How is remission maintained/relapse treated in crohns?
- Immunosuppressant medication : azathioprine, mercaptpurine, methotrexate
- Infliximab, adalimumab if necessary
Give 3 complications of crohns
- Bowel strictures leading to obstruction
- Fistulae
- Abscess formation
What causes GORD ?
- Inappropriate relaxation of the lower oesophageal sphincter due to functional immaturity
- Most spontanesouly resolves by 12mnths of age and put on weight normally despite symptoms
Give 4 serious causes of GORD
- Cerebral palsy
- Other neurodevelopmental disorders
- Preterm infants
- Following surgery for oesopheal atresia or diaphragmatic hernia
What investigations are done for GORD ?
- Usually clinic
- 24hr oesophageal pH monitoring to assess degree of acid reflux
- Endoscopy with oesophageal biopsy
How is uncomplicated GORD managed ?
-Inert thickening agents to feeds and position upright after meals
How is more severe GORD managed?
- Acid suppression with ranitidine or PPI
- Severe : surgical fundoplication
Give 4 complications of GORD
- Failure to thrive in severe vomiting
- Oesophagitis
- Recurrent pulmonary aspiration
- Sandifer’s syndrome
What is sandifer’s syndrome ?
-Rare condition causing brief episodes of abnormal movements assocaited with GORD in infants
Give 2 characteristics of sandifer’s syndrome
- Torticollis : forceful contraction of the neck muscles
- Dystonia
Define Hirschsprung disease
-Congenital condition where the nerve cells in the myenteric plexus are absent (aganglionic) in the rectum and variable distance of the colon
Give 4 presenting signs of Hirschsprung
- Failure to pass meconium in the first 24 hrs of life
- Abdominal distention
- Later : bile-stained vomit
- If presentation is later in life : profound chronic constipation, abdo distention and growth failure
How is Hirschsprung diagnosed ?
-Suction rectal biopsy
How is Hirschsprung managed ?
- Initially : rectal washouts/irrigation to prevent enterocolitis
- Surgically : initial colostomy with removal of the aganglionic section, followed by anastomosing normally innervated bowel the the anus -> swenson
What is a severe complication of Hirschsprung disease ?
-Hirschsprung-Associated Enterocolitis (HAEC)
What can cause HAEC and how does it present ?
- C.diff
- Fever, abdo distention, diarrhoea (often bloody) and features of sepsis
How is HAEC managed ?
- IV antibiotics
- Fluid resus
- Decompression of obstructed bowel
Define ulcerative colitis
-Recurrent, inflammatory and ulcerating disease involving the mucosa of the colon
How does UC present ?
- Rectal bleeding, diarrhoea and colicky abdo pain
- Weight loss
- Growth failure
Give 3 extraintestinal signs of UC
- Arthritis
- Erythema nodosum
- Primary sclerosing cholangitis
Give 3 signs of UC on endoscopy + biopsy
- Continuous inflammation
- Begins in the rectum and travels proximally
- Possible crypt abscesses
How is remission induced in UC ?
- Mild : aminosalicylates (e.g. mesalazine) or corticosteroids
- More severe : IV corticosteroids or IV ciclosporin
How is remission maintained in UC
- Aminosalicylate
- Azathioprine
- Mercaptopurine
What is a complication of UC ?
-Increased risk of adenocarcinoma of the colon in adulthood
What is malrotation ?
-Malrotation of the small bowel during foetal life
How does malrotation present ?
- Bilious vomiting in the first few days of life
- can lead to volvus formation leading to an obstruction and ischaemic bowel
- Abdo pain and tenderness from peritonitis or ischaemic bowel
- Associated with exomphalos & hernia
How is malrotation diagnosed ?
-Abdo USS : whirlpool sign
How is malrotation managed ?
-Surgery to untwist the bowel : Ladd’s
What is intussusception and when does it occur?
- Invagination of proximal bowel into a distal segment
- Usually occurs between 6mnths and 2 yrs of age
How does intussusception present
- Concurrent viral illness !
- Severe colciky pain and pallor causing a child to draw their legs up
- Redcurrant jelly stool
- Palpable sausage shaped mass in the abdomen
- Intestinal obstruction : vomiting, constipation, abdo distention.
What is associated with intussusception
- Meckel diverticulum
- Henoch-Schonlein purpura
- Cystic fibrosis
- Intestinal polyps
What is Meckels diverticulum and how does it present ?
- Ileal remnant of the vitello-intestinal duct
- Presents with severe rectal bleeding
- Diverticulitis micking appendicitis
- Treated with surgical resection
How is intussusception diagnosed ?
- USS : target sign
- Contrast enema
How is intussusception managed ?
- Rectal air insufflation : therapeutic enema
- Surgery if reduction of air is ineffective
How is intussusception managed if there are signs of peritonitis ?
- Surgery
Give 4 complications of intussusception
- Obstruction
- Gangernous bowel
- Perforation
- Death
What is pyloric stenosis ?
-Hypertrophy of the pyloric muscle leading to narrowing and oulet obstruction
Give 4 clinical features of pyloric stenosis
- Projectile vomit
- Hunger after vomiting
- Failure to thrive
- Olive shaped mass in upper abdomen
What would a blood gas show in pyloric stenosis ?
Hypochloric metabolic alkalosis with low plasma sodium and potassium due to vomiting stomach contents
When does pyloric stenosis present ?
- First few weeks of life
What can be seen on abdo exam in pyloric stenosis ?
- Pyloric mass in RUQ (olive like )
- Gastric peristalsis seen as a wave moving from left to right across the abdomen
How is pyloric stenosis diagnosed ?
- Test feed
- USS
How is pyloric stenosis managed ?
- Ramstedt’s pyloromyotomy
- Correct fluid and electrolyte disturbance with IV fluids
Give 3 mechanical consequences of vomiting
- Mallory-Weiss tear
- Boerhaave’s syndrome
- Tears of the short gastric arteries resulting in shock and hemoperitoneum
Give 5 signs of more severe GORD
- Faltering growth
- Oesophagitis +/-stricture
- Apnoea
- Aspiration, wheezing, hoarseness
- Seizure like events
Give 3 common causes of viral gastroenteritis
- Rotavirus
- Norovirus
- Adenovirus -> less common, more subacute diarrhoea
How would E.coli present if causing gastroenteritis
- Abdo cramps, D&V
- The shiga toxin leads to HUS
- Abx should be avoided due to increased risk of HUS
What is the most common bacterial causes of gastroenteritis worldwide ?
- Campylobacter jejuni -> gram neg
- Abdo cramps, bloody diarrhoea, vomiting, fever
- Raw poultry, untreated water, unpasteurised milk
- Abx : azithromycin, ciprofloxacin
How would shigella gastroenteritis present ?
- Faeces contaminated food and water
- Bloody diarrhoea, abdo cramps, fever
- Shiga toxin -> HUS
- Severe : azithromycin or ciprofloxacin
Explain salmonella causes of gastroenteritis
- Raw eggs, poultry
- Watery diarrhoea
- Abx only in severe cases
How does bacillus cereus as a cause of gastroenteritis present ?
- Fried rice eaten at room temp
- Cereulide toxin produces abdo cramping and vomiting withing 5 hrs
- Diarrhoea within 8 hrs
- Resolves within 24
- Gram positive rod
Give a parasitic cause of gastroenteritis
- Giardia lamblia
- Tx with metronidazole
What are the principles of gastroenteritis management
- Barrier nursing
- Stool microscopy, culture and sensitivities
- Hydration -> attempt fluid challenge. Dioralyte can be used to rehydrate or IV fluid is needed
How can intestinal obstruction present and how is it diagnosed ?
- Persistent, possibly bilious vomiting
- Abdo pain and distention
- Failure. topass stool or wind
- Abnormal bowel sounds : high pitched ‘tinkling’, absent later
- XRAY : dilated bowel proximal and collapsed loops distal + absence of air in rectum
Define encopresis
- Faecal incontinence -> pathological at 4 yrs
- Chronic constipation causes the rectum to stretch and lose sensation.
- Only loose stool can bypass blockage and leak out
How is constipation managed if faecal impaction is present ?
- Movicol peadiatric plan
- Add stimulant after 2 wks if no change
- Add osmotic laxative (lactulose)
How is general constipation managed
- Movicol
- Add stimulant
- Add osmotic laxative
- Continue for several weeks after refulat bowel habit.
