Paeds GI Flashcards
What is constipation
infrequent, difficult passage of stool that may be accompanied by the sensation of incomplete bowel emptying.
What are the two most common types of constipation
idiopathic constipation
functional constipation –> meaning there is not a significant underlying cause other than simple lifestyle factors
Name 3 causes of secondary causes of constipation
- Hirschsprung’s disease
- cystic fibrosis
- hypothyroidism
- Spinal cord lesions
- Sexual abuse
- Intestinal obstruction
- Anal stenosis
- Cows milk intolerance
What are typical features of constipation in history
Less than 3 stools a week
Hard stools that are difficult to pass
Rabbit dropping stools
Straining and painful passages of stools
Abdominal pain
Rectal bleeding associated with hard stools
Faecal impaction causing overflow soiling, with incontinence of particularly loose smelly stools
Loss of the sensation of the need to open the bowels
What are typical features of constipation in examination
- Hard stools may be palpable in abdomen
What lifestyle factors can contribute to constipation
- Habitually not opening the bowels
- Low fibre diet
- Poor fluid intake and dehydration
- Sedentary lifestyle
- Psychosocial problems such as a difficult home or school environment (always keep safeguarding in mind)
What are red flag signs in constipation
- Not passing meconium within 48 hours of birth (cystic fibrosis or Hirschsprung’s disease)
- Neurological signs or symptoms, particularly in the lower limbs (cerebral palsy or spinal cord lesion)
- Vomiting (intestinal obstruction or Hirschsprung’s disease)
- Ribbon stool (anal stenosis)
- Abnormal anus (anal stenosis, inflammatory bowel disease or sexual abuse)
- Abnormal lower back or buttocks (spina bifida, spinal cord lesion or sacral agenesis)
- Failure to thrive (coeliac disease, hypothyroidism or safeguarding)
- Acute severe abdominal pain and bloating (obstruction or intussusception)
What are complications of constipation
- Pain
- Reduced sensation
- Anal fissures
- Haemorrhoids
- Overflow and soiling (Encopresis)
- Psychosocial morbidity
How is constipation managed
- Correct any reversible contributing factors, recommend a high fibre diet and good hydration
- if impacted = polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen as the first-line treatment
- add a stimulant laxative if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks eg lactulose
Maintenance = Movicol
- Faecal impaction may require a disimpaction regimen with high doses of laxatives at first
- Encourage and praise visiting the toilet. This could involve scheduling visits, a bowel diary and star charts.
Laxatives should be continued long term and slowly weaned off as the child develops a normal, regular bowel habit.
What is GORD
where contents from the stomach reflux through the lower oesophageal sphincter into the oesophagus, throat and mouth.
Is GORD common in babies
yes normal
there is immaturity of the lower oesophageal sphincter, allowing stomach contents to easily reflux into the oesophagus.
What % of infants stop having reflux by 1 year old
90%
What are signs of problematic reflux in babies
Chronic cough
Hoarse cry
Distress, crying or unsettled after feeding
Reluctance to feed
Pneumonia
Poor weight gain
Name some possible causes of vomiting
Overfeeding
Gastro-oesophageal reflux
Pyloric stenosis (projective vomiting)
Gastritis or gastroenteritis
Appendicitis
Infections such as UTI, tonsillitis or meningitis
Intestinal obstruction
Bulimia
What are red flag features of reflux/vomiting
- Not keeping down any feed
- Projectile or forceful vomiting
- Bile stained vomit
- Haematemesis or melaena
- Abdominal distention
- Reduced consciousness, bulging fontanelle or neurological signs
- Respiratory symptoms (aspiration and infection)
- Blood in the stools
- Signs of infection
- Rash, angioedema and other signs of allergy
- Apnoeas
What is lifestyle management for reflux/vomiting
Small, frequent meals
Burping regularly to help milk settle
Not over-feeding
Keep the baby upright after feeding (i.e. not lying flat)
What treatment can be used for reflux/vomiting
- Gaviscon mixed with feeds
- Thickened milk or formula (specific anti-reflux formulas are available)
- Proton pump inhibitors (e.g., omeprazole) where other methods are inadequate
What investigation can be used in severe cases of reflux/vomiting
barium meal and endoscopy
What is Sandifer’s Syndrome
rare condition causing brief episodes of abnormal movements cause gastro-oesophageal reflux in infants.
What are two ket features of Sandifer’s Syndrome
- 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
What is Intestinal Obstruction
a physical obstruction prevents the flow of faeces through the intestines. This blockage will lead to a back-pressure through the gastrointestinal system, causing vomiting.
aka absolute constipation
what are causes Intestinal Obstruction
Meconium ileus
Hirschsprung’s disease
Oesophageal atresia
Duodenal atresia
Intussusception
Imperforate anus
Malrotation of the intestines with a volvulus
Strangulated hernia
How does Intestinal Obstruction present
- Persistent vomiting. This may be bilious, containing bright green bile.
- Abdominal pain and distention
- Failure to pass stools or wind
- Abnormal bowel sounds. These can be high pitched and “tinkling” early in the obstruction and absent later.
what is the initial investigation of choice for Intestinal Obstruction
abdominal xray.
- dilated loops of bowel proximal to the obstruction
- absence of air in the rectum.
What is initial management for Intestinal Obstruction
- nil by mouth & inserting a NG tube to help drain the stomach and stop the vomiting.
- IV fluids to correct any dehydration and electrolyte imbalances, and keep them hydrated while waiting for definitive management of the underlying cause.
What is Pyloric Stenosis
Hypertrophy (thickening) and therefore narrowing of the pylorus
prevents food traveling from the stomach to the duodenum as normal.
what is a pyloric sphincter
a ring of smooth muscle the forms the canal between the stomach and the duodenum
How does pyloric stenosis present
presents in the first few weeks of life, with a hungry baby that is thin, pale and generally failing to thrive
** “projectile vomiting” **
how does pyloric stenosis present after feeding
peristalsis can be seen by observing the abdomen
firm, round mass can be felt in the upper abdomen –> hypertrophic muscle of pylorus
what does pyloric stenosis show on blood gas analysis
hypochloric (low chloride) metabolic alkalosis as the baby is vomiting the hydrochloric acid
How is pyloric stenosis diagnosed
abdominal ultrasound to visualise the thickened pylorus
How is pyloric stenosis treated
laparoscopic pyloromyotomy (known as “Ramstedt’s operation“)
An incision is made in the smooth muscle of the pylorus to widen the canal allowing that food to pass from the stomach to the duodenum as normal.
how does pyloric stenosis present on blood gas
hypochloraemic hypokalaemic alkalosis
What is the prognosis following laparoscopic pyloromyotomy
excellent
What is Gastroenteritis
inflammation all the way from the stomach to the intestines and presents with nausea, vomiting and diarrhoea.
What is Acute gastritis
inflammation of the stomach and presents with nausea and vomiting.
what is Enteritis
inflammation of the intestines and presents with diarrhoea
What is the MC cause of Gastroenteritis
viral causes - rotavirus in children
What is the main concern in Gastroenteritis
dehydration
What are DDx of Diarrhoea
- Infection (gastroenteritis)
- Inflammatory bowel disease
- Lactose intolerance
- Coeliac disease
- Cystic fibrosis
- Toddler’s diarrhoea
- Irritable bowel syndrome
- Medications (e.g. antibiotics)
What is the key management establishment needed for Gastroenteritis
whether they are able to keep themselves hydrated or whether they need admission for IV fluids
What are 2 common viral causative agents of gastroenteritis
Rotavirus
Norovirus
What e coli strain produced shiga toxin
E. coli 0157
how is e. coli spread
infected faeces, unwashed salads or contaminated water
What are symptoms of shiga toxin
abdominal cramps, bloody diarrhoea and vomiting
what can shiga toxin lead to
destroys blood cells and leads to haemolytic uraemic syndrome (HUS).
is the use of Abx indicated in shiga toxin
No, bc the use of antibiotics increases the risk of haemolytic uraemic syndrome
What is the MC bacterial cause of gastroenteritis worldwide
Campylobacter - “travellers diarrhoea”
gram negative bacteria that has a curved or spiral shap
How is Campylobacter spread
Raw or improperly cooked poultry
Untreated water
Unpasteurised milk
What are symptoms of Campylobacter Jejuni
flu-like prodrome peroid then
Abdominal cramps
Diarrhoea often with blood
Vomiting
Fever
is the use of Abx indicated in Campylobacter Jejuni
yes after ID organism with severe symptoms or RF like <3 failure or HIV
–> azithromycin or ciprofloxacin.
What is incubation and resolution period for Campylobacter
Incubation is usually 2 to 5 days. Symptoms resolve after 3 to 6 days
What is incubation and resolution period for shigella
incubation period is 1 to 2 days and symptoms usually resolve within 1 week without treatment
what is Bacillus Cereus
gram positive rod spread through inadequately cooked food.
fried rice
What toxin does Bacillus Cereus produce
cereulide
how does Bacillus Cereus present
- causes abdominal cramping and vomiting within 6 hours of ingestion
- watery diarrhoea after 6 hours
how long does it take for Bacillus Cereus to resolve
24 hours
What is Giardiasis
Giardia lamblia is a type of microscopic parasite. It lives in the small intestines of mammals.
What is the transmission pathway of giardiasis
faecal-oral transmission.
How is Giardiasis diagnosed
stool microscopy
How is Giardiasis treated
metronidazole
What can prevent gastroenteritis
Good hygiene
what is important hospital/home management for preventing spread of gastroenteritis
- Barrier nursing
- rigorous infection control
- Children need to stay off school until 48 hours after the symptoms have completely resolved.
how is causative organism and antibiotic sensitivities established in gastroenteritis
microscopy, culture and sensitivities stool sample
How are patients determines to tolerate self hydration and not require hospital admission for gastroenteritis
fluid challenge.
involves recording a small volume of fluid given orally every 5-10 minutes to ensure they can tolerate it.
If they are able to tolerate oral fluid and are adequately hydrated they can usually be managed at home
Name a Rehydration solution
dioralyte
name an antidiarrhoeal medication
loperamide
name an antiemetic medication
metoclopramide
Are Antidiarrhoeal and antiemetic medications recommended gastroenteritis
no
Name post-gastroenteritis complications
Lactose intolerance
Irritable bowel syndrome
Reactive arthritis
Guillain–Barré syndrome
What are primary features of Crohns
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)
What are primary features of Ulcerative Colitis
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
What are IBD
Crohns
Ulcerative Colitis
How does IBD present
perfuse diarrhoea, abdominal pain, bleeding, weight loss or anaemia.
systemically unwell during flares, with fevers, malaise and dehydration.
What are extra-intestinal manifestations of IBD
Finger clubbing
Erythema nodosum
Pyoderma gangrenosum
Episcleritis and iritis
Inflammatory arthritis
Primary sclerosing cholangitis (ulcerative colitis)
What blood tests can be ordered to investiagte IBD
- Full blood count for haemoglobin (low in anaemia) and platelet count (raised with inflammation)
- C-reactive protein (CRP) -> inflammation
- Urea and electrolytes (U&Es) indicate electrolyte imbalances and kidney function
- Liver function tests (LFTs) can show low albumin in severe disease (protein is lost in the bowel)
- Thyroid function tests for hyperthyroidism as a cause of diarrhoea
- Anti-tissue transglutaminase antibodies (anti-TTG) for coeliac disease as a differential diagnosis
What initial investigation is ordered for IBD
Faecal calprotectin
90% sensitive and specific for inflammatory bowel disease
What is the gold standard investigation for diagnosis of IBD
Endoscopy (Oesophago-gastroduodenoscopy and colonoscopy) with biposy
What imagining investigations can be ordered to look for complications of IBD
ultrasound, CT and MR
eg fistulas, abscesses and strictures
What MDT members might be involved in IBD care
paediatricians, specialist nurses, pharmacists, dieticians and surgeons
What is essential to monitor in children with IBD
monitor the growth and pubertal development
How are acute flares of crohns managed
First line are steroids (e.g. oral prednisolone or IV hydrocortisone).
if doesnt work consider + immunosuppressant medication
How is remission maintained in crohns
1st line
- Azathioprine
- Mercaptopurine
alt
-Methotrexate
- Infliximab
- Adalimumab
What is surgical management of crohns
surgically resect distal ileum
treat strictures and fistulas secondary to Crohn’s
How are acute flares of UC in mild to moderate disease maanged
1st line –> aminosalicylate (e.g. mesalazine oral or rectal)
2nd line –> corticosteroids (e.g. prednisolone)
How are acute flares managed in UC in severe disease
1st line –> IV corticosteroids (e.g. hydrocortisone)
2nd line –> IV ciclosporin
How is maintaining remission managed in UC
- Aminosalicylate (e.g. mesalazine oral or rectal)
- Azathioprine
- Mercaptopurine
What is surgical management of UC
Ulcerative colitis usually only affects the colon and rectum –>
removing the colon and rectum (panproctocolectomy)
permanent ileostomy
What is IBS
disturbance of the gut-brain interaction, resulting in troublesome abdominal and intestinal symptoms
functional disorder –> no ID bowel disease, abnormal function with normal bowel
What are 3 keys symptoms of IBS
I – Intestinal discomfort (abdominal pain relieved by opening bowels)
B – Bowel habit abnormalities (frequency)
S – Stool abnormalities (watery, loose, hard or associated with mucus)
what are common symptoms of IBS
Abdominal pain
Diarrhoea
Constipation
Fluctuating bowel habit
Bloating
Worse after eating
Improved by opening bowels
Passing mucus
What can trigger or worsen IBS symptoms
Anxiety
Depression
Stress
Sleep disturbance
Illness
Medications
Certain foods
Caffeine
Alcohol
What are DDx of IBS
- Bowel cancer
- Inflammatory bowel disease
- Coeliac disease
- Ovarian cancer (often presents with vague symptoms, particularly bloating in women over 50 years)
- Pancreatic cancer
