Paeds GI Flashcards
1
Q
What is constipation
A
infrequent, difficult passage of stool that may be accompanied by the sensation of incomplete bowel emptying.
2
Q
What are the two most common types of constipation
A
idiopathic constipation
functional constipation –> meaning there is not a significant underlying cause other than simple lifestyle factors
3
Q
Name 3 causes of secondary causes of constipation
A
- Hirschsprung’s disease
- cystic fibrosis
- hypothyroidism
- Spinal cord lesions
- Sexual abuse
- Intestinal obstruction
- Anal stenosis
- Cows milk intolerance
4
Q
What are typical features of constipation in history
A
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
5
Q
What are typical features of constipation in examination
A
- Hard stools may be palpable in abdomen
6
Q
What lifestyle factors can contribute to constipation
A
- 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)
7
Q
What are red flag signs in constipation
A
- 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)
8
Q
What are complications of constipation
A
- Pain
- Reduced sensation
- Anal fissures
- Haemorrhoids
- Overflow and soiling (Encopresis)
- Psychosocial morbidity
9
Q
How is constipation managed
A
- 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.
10
Q
What is GORD
A
where contents from the stomach reflux through the lower oesophageal sphincter into the oesophagus, throat and mouth.
11
Q
Is GORD common in babies
A
yes normal
there is immaturity of the lower oesophageal sphincter, allowing stomach contents to easily reflux into the oesophagus.
12
Q
What % of infants stop having reflux by 1 year old
A
90%
13
Q
What are signs of problematic reflux in babies
A
Chronic cough
Hoarse cry
Distress, crying or unsettled after feeding
Reluctance to feed
Pneumonia
Poor weight gain
14
Q
Name some possible causes of vomiting
A
Overfeeding
Gastro-oesophageal reflux
Pyloric stenosis (projective vomiting)
Gastritis or gastroenteritis
Appendicitis
Infections such as UTI, tonsillitis or meningitis
Intestinal obstruction
Bulimia
15
Q
What are red flag features of reflux/vomiting
A
- 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
16
Q
What is lifestyle management for reflux/vomiting
A
Small, frequent meals
Burping regularly to help milk settle
Not over-feeding
Keep the baby upright after feeding (i.e. not lying flat)
17
Q
What treatment can be used for reflux/vomiting
A
- 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
18
Q
What investigation can be used in severe cases of reflux/vomiting
A
barium meal and endoscopy
19
Q
What is Sandifer’s Syndrome
A
rare condition causing brief episodes of abnormal movements cause gastro-oesophageal reflux in infants.
20
Q
What are two ket features of Sandifer’s Syndrome
A
- 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
21
Q
What is Intestinal Obstruction
A
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
22
Q
what are causes Intestinal Obstruction
A
Meconium ileus
Hirschsprung’s disease
Oesophageal atresia
Duodenal atresia
Intussusception
Imperforate anus
Malrotation of the intestines with a volvulus
Strangulated hernia
23
Q
How does Intestinal Obstruction present
A
- 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.
24
Q
what is the initial investigation of choice for Intestinal Obstruction
A
abdominal xray.
- dilated loops of bowel proximal to the obstruction
- absence of air in the rectum.
25
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.
26
What is Pyloric Stenosis
Hypertrophy (thickening) and therefore narrowing of the pylorus
prevents food traveling from the stomach to the duodenum as normal.
27
what is a pyloric sphincter
a ring of smooth muscle the forms the canal between the stomach and the duodenum
28
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” **
29
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
30
what does pyloric stenosis show on blood gas analysis
hypochloric (low chloride) metabolic alkalosis as the baby is vomiting the hydrochloric acid
31
How is pyloric stenosis diagnosed
abdominal ultrasound to visualise the thickened pylorus
32
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.
33
how does pyloric stenosis present on blood gas
hypochloraemic hypokalaemic alkalosis
34
What is the prognosis following laparoscopic pyloromyotomy
excellent
35
What is Gastroenteritis
inflammation all the way from the stomach to the intestines and presents with nausea, vomiting and diarrhoea.
36
What is Acute gastritis
inflammation of the stomach and presents with nausea and vomiting.
37
what is Enteritis
inflammation of the intestines and presents with diarrhoea
38
What is the MC cause of Gastroenteritis
viral causes - rotavirus in children
39
What is the main concern in Gastroenteritis
dehydration
40
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)
41
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
42
What are 2 common viral causative agents of gastroenteritis
Rotavirus
Norovirus
43
What e coli strain produced shiga toxin
E. coli 0157
44
how is e. coli spread
infected faeces, unwashed salads or contaminated water
45
What are symptoms of shiga toxin
abdominal cramps, bloody diarrhoea and vomiting
46
what can shiga toxin lead to
destroys blood cells and leads to haemolytic uraemic syndrome (HUS).
47
is the use of Abx indicated in shiga toxin
No, bc the use of antibiotics increases the risk of haemolytic uraemic syndrome
48
What is the MC bacterial cause of gastroenteritis worldwide
Campylobacter - "travellers diarrhoea"
gram negative bacteria that has a curved or spiral shap
49
How is Campylobacter spread
Raw or improperly cooked poultry
Untreated water
Unpasteurised milk
50
What are symptoms of Campylobacter Jejuni
flu-like prodrome peroid then
Abdominal cramps
Diarrhoea often with blood
Vomiting
Fever
51
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.
52
What is incubation and resolution period for Campylobacter
Incubation is usually 2 to 5 days. Symptoms resolve after 3 to 6 days
53
What is incubation and resolution period for shigella
incubation period is 1 to 2 days and symptoms usually resolve within 1 week without treatment
54
what is Bacillus Cereus
gram positive rod spread through inadequately cooked food.
fried rice
55
What toxin does Bacillus Cereus produce
cereulide
56
how does Bacillus Cereus present
* causes abdominal cramping and vomiting within 6 hours of ingestion
* watery diarrhoea after 6 hours
57
how long does it take for Bacillus Cereus to resolve
24 hours
58
What is Giardiasis
Giardia lamblia is a type of microscopic parasite. It lives in the small intestines of mammals.
59
What is the transmission pathway of giardiasis
faecal-oral transmission.
60
How is Giardiasis diagnosed
stool microscopy
61
How is Giardiasis treated
metronidazole
62
What can prevent gastroenteritis
Good hygiene
63
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.
64
how is causative organism and antibiotic sensitivities established in gastroenteritis
microscopy, culture and sensitivities stool sample
65
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
66
Name a Rehydration solution
dioralyte
67
name an antidiarrhoeal medication
loperamide
68
name an antiemetic medication
metoclopramide
69
Are Antidiarrhoeal and antiemetic medications recommended gastroenteritis
no
70
Name post-gastroenteritis complications
Lactose intolerance
Irritable bowel syndrome
Reactive arthritis
Guillain–Barré syndrome
71
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)
72
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
73
What are IBD
Crohns
Ulcerative Colitis
74
How does IBD present
perfuse diarrhoea, abdominal pain, bleeding, weight loss or anaemia.
systemically unwell during flares, with fevers, malaise and dehydration.
75
What are extra-intestinal manifestations of IBD
Finger clubbing
Erythema nodosum
Pyoderma gangrenosum
Episcleritis and iritis
Inflammatory arthritis
Primary sclerosing cholangitis (ulcerative colitis)
76
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
77
What initial investigation is ordered for IBD
Faecal calprotectin
90% sensitive and specific for inflammatory bowel disease
78
What is the gold standard investigation for diagnosis of IBD
Endoscopy (Oesophago-gastroduodenoscopy and colonoscopy) with biposy
79
What imagining investigations can be ordered to look for complications of IBD
ultrasound, CT and MR
eg fistulas, abscesses and strictures
80
What MDT members might be involved in IBD care
paediatricians, specialist nurses, pharmacists, dieticians and surgeons
81
What is essential to monitor in children with IBD
monitor the growth and pubertal development
82
How are acute flares of crohns managed
First line are steroids (e.g. oral prednisolone or IV hydrocortisone).
if doesnt work consider + immunosuppressant medication
83
How is remission maintained in crohns
1st line
- Azathioprine
- Mercaptopurine
alt
-Methotrexate
- Infliximab
- Adalimumab
84
What is surgical management of crohns
surgically resect distal ileum
treat strictures and fistulas secondary to Crohn’s
85
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)
86
How are acute flares managed in UC in severe disease
1st line --> IV corticosteroids (e.g. hydrocortisone)
2nd line --> IV ciclosporin
87
How is maintaining remission managed in UC
- Aminosalicylate (e.g. mesalazine oral or rectal)
- Azathioprine
- Mercaptopurine
88
What is surgical management of UC
Ulcerative colitis usually only affects the colon and rectum -->
removing the colon and rectum (panproctocolectomy)
permanent ileostomy
89
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
90
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)
91
what are common symptoms of IBS
Abdominal pain
Diarrhoea
Constipation
Fluctuating bowel habit
Bloating
Worse after eating
Improved by opening bowels
Passing mucus
92
What can trigger or worsen IBS symptoms
Anxiety
Depression
Stress
Sleep disturbance
Illness
Medications
Certain foods
Caffeine
Alcohol
93
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
94
How blood tests can be order to investigate DDx for IBS
- Full blood count for anaemia
- Inflammatory markers (e.g., ESR and CRP)
- Coeliac serology (e.g., anti-TTG antibodies)
- Faecal calprotectin for inflammatory bowel disease
- CA125 for ovarian cancer
95
How is IBS diagnosed
diagnosis of exclusion
at least 6 months of abdominal pain or discomfort with at least one of:
- Pain or discomfort relieved by opening the bowels
- Bowel habit abnormalities (more or less frequent)
- Stool abnormalities (e.g., watery, loose or hard)
also require at least two of:
- Straining, an urgent need to open bowels or incomplete emptying
- Bloating
- Worse after eating
- Passing mucus
96
What lifestyle advice can be given for IBS
- Drinking enough fluids
- Regular small meals
- Adjusting fibre intake according to symptoms
- Limit caffeine, alcohol and fatty foods
- Low FODMAP diet, guided by a dietician
- Probiotic supplements may be considered over-the-counter
- Reduce stress where possible
- Regular exercise
97
What is a medication for diarrhoea
Loperamide
98
what is a medication for constipation
ispaghula husk
99
what medication can be used for abdominal cramps
Antispasmodics
mebeverine, alverine, hyoscine butylbromide or peppermint oil
however weak evidence
100
What medication can be used for constipation in IBS when first-line laxatives are inadequate.
Linaclotide
101
What are other management options when IBS symptoms remain uncontrolled (psych adjacent)
- Low-dose tricyclic antidepressants (e.g., amitriptyline)
- SSRI antidepressants
- Cognitive behavioural therapy (CBT)
- Specialist referral for further management
102
what is Hirschsprung’s
congenital condition where nerve cells of the myenteric plexus are absent in the distal bowel and rectum
absence of parasympathetic ganglion cells
103
what is myenteric plexus also known as and what does it form
Auerbach’s plexus
forms the enteric nervous system. It is the brain of the gut.
104
What does myenteric plexus do
responsible for stimulating peristalsis of the large bowel.
GI tract motility
105
What is the pathophysiology of development of Hirschsprung’s
when the parasympathetic ganglion cells do not travel all the way down the colon in fetal development, and a section of colon at the end is left without these parasympathetic ganglion cells.
106
What is it called when the entire colon is affected by Hirschsprung’s
total colonic aganglionosis
107
Is the part of the colon affected by Hirschsprung’s constricted or relaxed
The aganglionic section of colon does not relax, causing it to becomes CONSTRICTED
108
What conditions are associated with Hirschsprung’s
- Downs syndrome
- Neurofibromatosis
- Waardenburg syndrome (a genetic condition causing pale blue eyes, hearing loss and patches of white skin and hair)
- Multiple endocrine neoplasia type II
109
How does Hirschsprung’s present
- presents in neonate peroid
- Delay in passing meconium (more than 24 hours)
- Chronic constipation since birth
- Abdominal pain and distention
- Vomiting
- Poor weight gain and failure to thrive
- After the PR there may be an improvement in symptoms
110
What is Hirschsprung-Associated Enterocolitis
inflammation and obstruction of the intestine occurring in around 20% of neonates with Hirschsprung’s disease.
111
What is a life threatening complication of Hirschsprung in neonates
Hirschsprung-associated enterocolitis
can lead to toxic megacolon and perforation of the bowel.
112
How does Hirschsprung-associated enterocolitis present
within 2-4 weeks of birth
with fever, abdominal distention, diarrhoea (often with blood) and features of sepsis.
113
how is Hirschsprung-associated enterocolitis managed
urgent IV antibiotics, fluid resuscitation and decompression of the obstructed bowel.
114
What is 1st line investigation for Hirschsprung
Abdominal xray can be helpful in diagnosing intestinal obstruction
115
How is Hirschsprung diagnosis confirmed and what will it show
Rectal biopsy
histology will show absence of ganglionic cells.
116
What is the definitive management of Hirschsprung
surgical removal of the aganglionic section of bowel
117
What is coeliac disease
autoimmune condition where exposure to gluten causes an immune reaction that creates inflammation in the small intestine
118
what autoantibodies do people with coeliac disease produce in response to gluten exposure
- anti-tissue transglutaminase (anti-TTG)
- anti-endomysial (anti-EMA).
119
What cells are targeted in coeliac disease
epithelial cells
120
Where does inflammation in coeliac disease affect
small bowel, particularly the jejunum.
121
How does coeliac disease cause malabsorption
causes atrophy of the intestinal villi
122
What human leukocyte antigen (HLA) are associated with coeliac disease
HLA-DQ2
HLA-DQ8
123
A new diagnosis of what two conditions requires testing for coeliac disease
type 1 diabetes & autoimmune thyroid disease
124
How does Coeliac disease present
often asymptomatic
- Failure to thrive in young children
- Diarrhoea
- Fatigue
- Weight loss
- Mouth ulcers
- Anaemia secondary to iron, B12 or folate deficiency
- Dermatitis herpetiformis is an itchy blistering skin rash that typically appears on the abdomen
125
What are rare neurological symptoms of Coeliac disease
Peripheral neuropathy
Cerebellar ataxia
Epilepsy
126
What class of antibody is Anti-TTG and anti-EMA antibodies
IgA
127
What is important to remember when testing for antibodies in coeliac
to test for total Immunoglobulin A levels
--> if total IgA is low the coeliac test will be negative even when they have the condition
128
What are first line blood tests for coeliac
- Raised anti-TTG antibodies (first choice)
- Raised anti-endomysial antibodies
- Total immunoglobulin A levels to exclude IgA deficiency
129
what is the definitive diagnosis for coeliac and what are the findings
Endoscopy and intestinal biopsy
- Crypt hyperplasia
- Villous atrophy
130
How is coeliac managed
lifelong gluten-free diet
131
what are complications of untreated coeliac
- Nutritional deficiencies
- Anaemia
- Osteoporosis
- Ulcerative jejunitis
- Enteropathy-associated T-cell lymphoma (EATL)
- Non-Hodgkin lymphoma
- Small bowel adenocarcinoma
132
What is Appendicitis
inflammation of the appendix
133
What part of the bowel is the appendix attached to
caecum
134
What causes appendicitis
becomes inflamed due to infection trapped in the appendix by obstruction at the point where the appendix meets the bowel
135
What can untreated appendicitis lead to
gangrene and rupture
peritonitis
136
What is the peak incidence of appendicitis
10 to 20 years.
137
What is the central presenting feature of appendicitis
central abdominal pain, that moves down to the right iliac fossa (RIF) over time and eventually becomes localised in the RIF
138
What is the examination finding for appendicitis
Tenderness in McBurney’s point.
Rovsing’s sign
Rebound tenderness
Guarding on abdo palpation
Percussion tenderness
139
Where is McBurney’s point
one third the distance from the anterior superior iliac spine (ASIS) to the umbilicus.
140
What is Rovsings sign
palpation of the left iliac fossa causes pain in the RIF
141
What is rebound tenderness
increased pain when quickly releasing pressure on the right iliac fossa
142
What does rebound tenderness and percussion tenderness suggest
peritonitis, caused by a ruptured appendix.
143
How is appendicitis diagnosed
clinical presentation and raised inflammatory markers
CT Scan/US to excluded obgyn ddx
144
What is the investigation when a patient has a clinical presentation suggestive of appendicitis but investigations are negative
perform a diagnostic laparoscopy to visualise the appendix directly.
145
What are key DDx of appendicitis
- Ectopic Pregnancy
- Ovarian Cysts
- Meckel’s Diverticulum
- Mesenteric Adenitis
- Appendix mass
146
How is appendicitis managed
emergency admission to hospital under the surgical team
definitive = Removal of the inflamed appendix (appendicectomy) Laparoscopic
147
What are Complications of Appendicectomy
- Bleeding, infection, pain and scars
- Damage to bowel, bladder or other organs
- Removal of a normal appendix
- Anaesthetic risks
- Venous thromboembolism (deep vein thrombosis or pulmonary embolism)
148
What is intussusception
condition where the bowel “invaginates” or “telescopes” into itself.
This thickens the overall size of the bowel and narrows the lumen at the folded area, leading to a palpable mass in the abdomen and obstruction to the passage of faeces through the bowel. I
149
Who does Intussusception typically affect
infants 6 months to 2 years
more common in boys.
150
What conditions is intussusception associated with
- Concurrent viral illness
- Henoch-Schonlein purpura
- Cystic fibrosis
- Intestinal polyps
- Meckel diverticulum
151
How does intussusception present
- ** redcurrant jelly stool **
- ** Right upper quadrant mass on palpation. This is described as “sausage-shaped” **
- Severe, colicky abdominal pain
- Pale, lethargic and unwell child
- viral URT infection
- Vomiting
- Intestinal obstruction
152
How is intussusception diagnosed
ultrasound scan
A classic target or bull's eye sign seeen
153
What is first line management for intussusception
Therapeutic enemas - reduction with air insufflation
Contrast, water or air are pumped into the colon to force the folded bowel out of the bowel and into the normal position.
154
What is the management when enemas do not work
Surgical reduction
155
When is surgical resection required for intussusception
If the bowel becomes gangrenous (due to a disruption of the blood supply) or the bowel is perforated
156
what are complications of intussusception
Obstruction
Gangrenous bowel
Perforation
Death
157
What is biliary atresia
congenital condition where a section of the bile duct is either narrowed or absent.
158
What does biliary atresia result in
results in cholestasis
bile cannot be transported from the liver to the bowel
= prevents the excretion of conjugated bilirubin
159
When should biliary atresia be suspected
in babies with a persistent jaundice, lasting more than 14 days in term babies and 21 days in premature babies
160
What is initial investigation for biliary atresia
conjugated and unconjugated bilirubin
will have high conjugated bilirubin levels
161
Why is conjugated bilirubin high in biliary atresia
the liver is processing the bilirubin for excretion (by conjugating it), but it is not able to excrete the conjugated bilirubin because it cannot flow through the biliary duct into the bowel.
162
How is biliary atresia managed
surgical
“Kasai portoenterostomy”
creating a connection between the liver and the small intestine to allow for bile drainage
163
What is a hernia
weakness in cavity wall that allows body organ (e.g., bowel) that would normally be contained within that cavity to pass through the cavity wall
164
how does a hernia present
- A soft lump protruding from the abdominal wall
- The lump may be reducible (it can be pushed back into the normal place)
- The lump may protrude on coughing (raising intra-abdominal pressure) or standing (pulled out by gravity)
- Aching, pulling or dragging sensation
165
What are three key complications of hernias
- Incarceration
- Obstruction
- Strangulation
166
what is hernia incarceration
where the hernia cannot be reduced back into the proper position
167
what is hernia obstruction
where a hernia causes a blockage in the passage of faeces through the bowel.
168
what is hernia strangulation
where a hernia is non-reducible (it is trapped with the bowel protruding) and the base of the hernia becomes so tight that it cuts off the blood supply, causing ischaemia.
169
What feature of hernias is used to formulate risk assessment and management plan
size of the neck/defect (narrow or wide)
Hernias that have a wide neck, meaning that the size of the opening that allows abdominal contents through is large, are at lower risk of complications.
170
What are the 3 general principles of hernia management
Conservative management
Tension-free repair (surgery)
Tension repair (surgery)
171
What is conservative management for abdominal hernias
involves leaving the hernia alone
most appropriate when the hernia has a wide neck
172
What is tension free repair for abdominal hernias
placing a mesh over the defect in the abdominal wall.
Mesh is sutured to the muscles and tissues on either side of the defect, covering it and preventing herniation of the cavity contents.
MC
173
what is a tension repair of abdominal hernias
suture the muscles and tissue on either side of the defect back together
174
What are two types of inguinal hernias
Indirect inguinal hernia
Direct inguinal hernia
175
What is a Direct inguinal hernia
hernia protrudes directly through the abdominal wall, through Hesselbach’s triangle
176
What is an indirect inguinal hernia
the bowel herniates through the inguinal canal.
goes into scrotum
177
What are DDx for inguinal hernia
- Femoral hernia
- Lymph node
- Saphena varix (dilation of saphenous vein at junction with femoral vein in groin)
- Femoral aneurysm
- Abscess
- Undescended / ectopic testes
- Kidney transplant
178
How do you differentiate direct from indirect inguinal hernias
in INDIRECT hernias --> when pressure is applied to the deep inguinal ring, the hernia will remain reduced.
pressure over deep inguinal ring will not stop herniation in direct
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when is the deep inguinal ring located
at the mid-way point from the ASIS to the pubic tubercle
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What are boundaries of Hesselbach’s triangle
- R – Rectus abdominis muscle – medial border
- I – Inferior epigastric vessels – superior / lateral border
- P – Poupart’s ligament (inguinal ligament) – inferior border
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What is Cow's Milk Protein Allergy
hypersensitivity to the protein in cow’s milk
typically affecting infants and young children under 3 years.
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how can Cow's Milk Protein Allergy reaction occur
IgE mediated --> rapid reaction w/in 2 hours
non-IgE medicated --> occurring slowly over several days
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Who is cow's milk protein allergy more common in
more common in formula fed babies and those with a personal or family history of other atopic conditions.
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What are gastrointestinal symptoms of cow's milk protein allergy
- Bloating and wind
- Abdominal pain
- Diarrhoea
- Vomiting
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what are general allergic symptoms of cow's milk protein allergy
- Urticarial rash (hives)
- Angio-oedema (facial swelling)
- Cough or wheeze
- Sneezing
- Watery eyes
- Eczema
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How is cow's milk protein allergy diagnosed
based on a full history and examination
Skin prick testing can help support the diagnosis but is not always necessary
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How is cow's milk protein allergy managed
Avoiding cow’s milk should fully resolve symptoms:
Breast feeding mothers should avoid dairy products
Replace formula with special hydrolysed formulas designed for cow’s milk allergy --> protein removed
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What is prognosis for cow's milk protein allergy
Most children will outgrow cow’s milk protein allergy by age 3, often earlier
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What steps should be taken to resolve cow's milk protein allergy
Every 6 months or so, infants can be tried on the first step of the milk ladder and then slowly progress up the ladder until they develop symptoms
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What is Meckel’s diverticulum
* congenital diverticulum of the small intestine
* remnant of the omphalomesenteric duct
* occurs in 2% of the population
* is 2 feet from the ileocaecal valve
* is 2 inches long
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How is Meckel’s diverticulum investigated
FBC
technetium-99m pertechnetate scan ('Meckel's scan')
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How does Meckel’s diverticulum present
usually asymptomatic
however it can bleed, become inflamed, rupture or cause a volvulus or intussusception
passage of bright red stool
intractable constipation
number 1 cause of painless massive GI bleeding in 1-2yr
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How is Meckel’s diverticulum managed
if asymptomatic --> treatment not required
if symptomatic --> excision of diverticulum
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What is Kwashiorkor
dietary protein deficiency
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What is Kwashiorkor associated with
corn-based diet, recent weaning, measles, or diarrhoeal illness
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How does Kwashiorkor present
affects children 6months to 3 years
bilateral pitting oedema, in the absence of another medical cause of oedema
protruding stomach
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What is Failure to thrive
poor physical growth and development in a child
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what is Faltering growth
as a fall in weight across:
- One or more centile spaces if their birthweight was below the 9th centile
- Two or more centile spaces if their birthweight was between the 9th and 91st centile
- Three or more centile spaces if their birthweight was above the 91st centile
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What are causes of Failure to Thrive
Inadequate nutritional intake
Difficulty feeding
Malabsorption
Increased energy requirements
Inability to process nutrition
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what are causes of inadequate nutritional intake
Maternal malabsorption if breastfeeding
Iron deficiency anaemia
Family or parental problems
Neglect
Availability of food (i.e. poverty)
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what are causes of difficulty feeding
Poor suck, for example due to cerebral palsy
Cleft lip or palate
Genetic conditions with an abnormal facial structure
Pyloric stenosis
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What are causes of malabsorption
Cystic fibrosis
Coeliac disease
Cows milk intolerance
Chronic diarrhoea
Inflammatory bowel disease
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what are causes of increaaed energy requirements
Hyperthyroidism
Chronic disease, for example congenital heart disease and cystic fibrosis
Malignancy
Chronic infections, for example HIV or immunodeficiency
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what are causes of inability to process nutrients properly
Inborn errors of metabolism
Type 1 diabetes
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what is the aim of assessment for failure to thrive
establish the cause of the failure to thrive
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What key areas need to be assessed in a failure to thrive assessment
- Height, weight and BMI (if older than 2 years) and plotting these on a growth chart **
- Calculate the mid-parental height centile **
- Pregnancy, birth, developmental and social history
- Feeding or eating history
- Observe feeding
- Mums physical and mental health
- Parent-child interactions
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what does a feeding history involve
breast or bottle feeding
feeding times
volume
frequency
any difficulties with feeding
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what does an eating history involve
food choices
food aversion
meal time routines
appetite in children
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how is BMI calculated
(weight in kg) / (height in meters)2.
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how is mid parental height calculated
(height of mum + height of dad) / 2.
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What outcome of BMI or mid parental height centile suggests an inadequate nutrition or a growth disorder are:
- Height more than 2 centile spaces below the mid-parental height centile
- BMI below the 2nd centile
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What are initial investigations for failure to thrive
Urine dipstick, for urinary tract infection
Coeliac screen (anti-TTG or anti-EMA antibodies)
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What support is there for difficulty breast feeding
midwives, health visitors, peers groups and “lactation consultants”.
Supplementing with formula milk
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what are management options when inadequate nutrition is cause of faltering growth
- Encouraging regular structured mealtimes and snacks
- Reduce milk consumption to improve appetite for other foods
- Review by a dietician
- Additional energy dense foods to boost calories
- Nutritional supplements drinks
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what is marasmus
due to deficiency of proteins and calories
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how does marasmus present
severe reduction in body weight
shrunken abdo
prominent ribs
no fatty liver and no oedema
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What is a choledochal cyst
rare, congenital condition that causes the bile ducts to swell before birth
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how does a choledochal cyst present
Abdominal pain, palpable abdominal mass, and jaundice
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How are choledochal cyst investigated
US
CT cholangiography - more accurate
Technectium-99 HIDA scan
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what is the gold standard investigation for choledochal cyst
Magnetic Resonance Cholangiopancreatography (MRCP)
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How is choledochal cyst managed
radical surgical excision
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What are complications of choledochal cyst
Malignancy
Stricture
Ascending Cholangitis
Sludge and Stone Formation
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What are DDx for choledochal cyst
Hepatic cysts
Duodenal atresia
Mesenteric or omental cysts
Intestinal duplication
Gallbladder duplication
Ovarian cysts
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What is neonatal hepatitis
inflammation of the liver that occurs only in early infancy, usually between one and two months after birth
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Name infective causes of neonatal hepatitis
cytomegalovirus, rubella (measles) and hepatitis A, B or C viruses.
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How is neonatal hepatitis investigated
liver biopsy
blood tests
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How does neonatal hepatitis present
jaundice
enlarged liver
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how is neonatal hepatitis differentied from biliary atresia
liver biopsy
often show that four or five liver cells are combined into a large cell w poor function
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How is neonatal hepatitis treated
no specific treatment for neonatal hepatitis
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what is phenobarbital
stimulates the liver to excrete additional bile
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what is key sign of intestinal malrotation
bilious vomiting
he green colour of the vomit is caused by conditions that cause intestinal obstruction distal to the ampulla of Vater. After this point, the bile is mixed with the intestinal contents, giving the vomit the classical green colour
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what is intestinal malrotation associated with
Exomphalos and diaphragmatic herniae
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how is intestinal malrotation with volvulus managed
Ladd's procedure
