Paeds GI Flashcards
What is Hirschprung’s?
- congenital condition
- nerve cells of myenteric plexus are absent in distal bowel and rectum
What is the myenteric plexus?
- Auerbach’s plexus
- enteric nervous system
- brain of the gut
What is the pathophysiology of Hirschprung’s?
- absence of PS ganglion cells
- PS cells do not migrate down from higher in GI tract
What causes Hirschprung’s?
- genetic
- FHx inc chance
How does Hirschprung’s cause obstruction?
- aganglionic colon
- loss of movement of faeces
- obstruction in bowel
- proximal to obstruction: distention and fullness
How does Hirschprung’s present?
- delay in passing meconium
- chronic constipation since birth
- abdo pain and distention
- vomiting
- poor weight gain and FTT
What syndromes is Hirschprung’s associated with?
- Down’s
- Neurofibromatosis
- Waardenburg syndrome
- multiple endocrine neoplasia type II
What is Hirschprung-Associated Enterecolitis?
- inflammation and obstruction of intestine
- occurs in 20% neonates w/ Hirschprung’s
- presents 2-4 weeks after birth
How does hirschprung-associated enterocolitis present?
- fever
- abdo distention
- (bloody) diarrhoea
- sepsis features
- can lead to toxic megacolon and bowel perf
How is hirschprung-associated enterocolitis managed?
- urgent Abx
- fluid resus
- decompression of obstruction
How is Hirschprung’s investigated?
- Abdo x-ray
- rectal biopsy
- histology showing absence of ganglionic cells
How is Hirschprung’s managed?
- fluid resus if unwell
- rectal washout
- surgical removal of aganglionic section: pull-through
- may be left with disturbances of function/incontinence
What is intussusception?
- bowel invaginates into itself
- thickens overall size and narrows lumen
- obstructs passage of faeces
What is the epidemiology of intussusception?
- infants 6mo - 2yrs
- more common in boys
What conditions are associated with intussusception?
- concurrent viral illness
- HSP
- cystic fibrosis
- intestinal polyps
- Meckel’s diverticulum
How does intussusception present?
- severe, colicky abdo pain
- drawing knees to chest
- pale, lethargic, unwell
- redcurrant jelly stool
- sausage shaped RUQ mass
- vomiting
- intestinal obstruction
How is intussusception diagnosed?
- USS
- contrast enema
How is intussusception managed?
- therapeutic enema
- contrast/water/air pumped into colon to force normal position
- surgical reduction
- surgical resection if gangrenous
What are some complications of intussusception?
- obstruction
- gangrenous bowel
- perforation
- death
What is the pyloric sphincter?
- ring of smooth muscle forming the canal between the stomach and duodenum
What is pyloric stenosis?
- hypertrophy and narrowing of the pylorus
- prevents food travelling to duodenum as normal
How does pyloric stenosis present?
- 2-8 week baby
- projectile non bilious vomiting
- thin pale baby
- failure to thrive
Why is there projectile vomiting in pyloric stenosis?
- peristalsis tries to push food into duodenum
- ejects food into oesophagus and out of mouth
What is seen on examination of pyloric stenosis?
- firm round mass in upper abdomen
- feels like large olive
What is seen metabolically on investigation of pyloric stenosis?
- hypochloemic, hypokalaemic metabolic alkalosis
- due to vomiting HCl acid
How is pyloric stenosis diagnosed?
- abdo USS: target sign (hypertrophic pylorus)
How is pyloric stenosis managed?
- NBM with IV fluids
- Ramstedt pyloromyotomy to widen canal (laparoscopic)
What is appendicitis and what is the epidemiology?
- inflammation of the appendix
- patients aged 10-20 yrs
What is the anatomy of the appendix?
- small, thin tube arising from caecum, leads to dead end
- located where 3 teniae coli meet
What is the pathophysiology behind appendicitis?
- pathogens trapped due to obstruction where the appendix meets the bowel
- trapped pathogens > infection + inflammation
- can lead to gangrene and rupture > faeces and infectious material released into peritoneum
- leads to peritonitis
What is the presentation of appendicitis?
- central abdo pain > R iliac fossa
- tenderness at McBurney’s point on palpation
- loss of appetite
- nausea and vomiting
- guarding
- rebound and percussion tenderness
What is Rovsing’s sign?
- palpation of the LIF causes pain in the RIF
What is rebound tenderness?
- increased pain when quickly releasing pressure
How is appendicitis diagnosed?
- clinical presentation
- raised inflammatory markers
- CT/ultrasound
- potential diagnostic laparoscopy
What are the key differential diagnoses of appendicitis?
- ovarian cysts
- Meckel’s diverticulum
- ectopic pregnancy (hCG to exclude)
How is appendicitis managed?
- appendectomy
- laparoscopic surgery is ideal over open
What is biliary atresia?
- congenital narrowing or absence of bile duct
- prevents excretion of conjugated bilirubin
How does biliary atresia present?
- persistent jaundice
- in term babies if >14 days
- > 21 days in prem babies
How is biliary atresia investigated?
- conjugated and unconjugated bilirubin levels
How is biliary atresia managed?
- Kasai portoenterostomy
- attaching section of small intestine to liver where bile duct normally attaches
- or full liver transplant
What are the typical characteristics of Crohn’s (NESTS)
- No blood or mucus
- Entire GI tract (mainly ileum)
- Skip lesions: unaffected areas between active disease
- Terminal ileum (and proximal colon) most affected with transmural inflammation
- Smoking is a risk factor
What are the characteristics of ulcerative colitis (CLOSE)?
- continuous inflammation
- limited to colon and rectum
- only superficial mucosa affected
- smoking is protective
- excreted blood and mucus
How does IBD present?
- diarrhoea
- abdominal pain
- passing blood
- weight loss
- anaemia
What are some extra-intestinal manifestations of IBD?
- clubbing
- erythema nodosum
- inflammatory arthritis
What are some specific features of the presentation of ulcerative colitis?
- blood and mucus with gradual onset of diarrhoea
- bowel frequency related to severity of disease
- crampy abdominal discomfort
How is IBD investigated?
- bloods: anaemia, FBC, U&Es, cultures
- CRP
- faecal calprotectin
- endoscopy
- GOLD: colonoscopy and biopsy
- imaging for complications
How is moderate UC managed medically?
inducing remission:
- 1st line: aminosalocylate (mesalazine)
- 2nd line: corticosteroids: prednisolone
How is severe UC managed medically?
- hydrocortisone ± cyclosporin if severe
- maintaining remission: sulfasalazine, mesalazine
How is UC managed surgically?
- panproctocolectomy (colon removal)
- permanent ileostomy or J-pouch
How is Crohn’s managed medically?
- inducing remission: steroids: prednisolone
- hydrocortisone if severe
- maintaining remission: azathioprine, methotrexate
What is the surgical management of Crohn’s?
- if only affecting distal ileum can be resected
- surgery to treat strictures and fistulas
What is the pathophysiology of IBD?
- develops as a result of environmental trigger in genetically susceptible individual
- bacteria or dietary antigens taken up by M cells, pass through gap between cells
- picked up by antigen presenting cells causing secretion of pro-inflammatory cytokines
- activates T cells leading to inflammation
What is irritable bowel syndrome?
- functional bowel disorder
- symptoms resulting from abnormal functioning of bowel
- due to disorders of gut motility or brain-gut axis
What are the symptoms of IBS?
- fluctuating bowel habit: alternating constipation and diarrhoea
- abdominal pain relieved by defecation
- bloating
- chronic and exacerbated by stress
How is IBS diagnosed?
- exclusion: bloods, faecal calprotectin (IBD), anti-TTG (coeliac), colonoscopy
- abdo pain + 2 symptoms
How is IBS managed?
- try exclusion diets
- reduced processed food, caffeine and alcohol
- regular small meals and fluid
- loperamide for diarrhoea
- laxatives for constipation
- tricyclic antidepressants, SSRIs
What is typical presentation of constipation?
- <3 stools per week
- hard or rabbit dropping stools
- straining and painful passage
- abdo pain
- overflow soiling
- retentive posturing
- rectal bleeding
What lifestyle factors cause constipation?
- habitually not opening bowels
- low fibre diet
- poor fluid intake
- sedentary lifestyle
- psychosocial problems
What is encopresis?
- faecal incontinence
- rectum loses sensation due to stretching
- overflow soiling
What is faecal impaction?
- large hard stool blocking rectum
- leading to desensitisation
What are red flags of constipation in newborns and infants?
- not passing meconium within 48hrs: CF, Hirschprung’s
- vomiting: intestinal obstruction
What physical exam findings are red flags in constipated children?
- Abnormal anus or lower back/buttocks (spina bifida, cord lesion, abuse)
- Neurological signs, especially in lower limbs (cerebral palsy, cord lesion)
What systemic signs are red flags in constipated children?
- Failure to thrive (coeliac, hypothyroidism, safeguarding)
- Acute severe abdominal pain and bloating (obstruction, intussusception)
How is constipation managed?
- high fibre diet
- hydration
- laxatives: movicol
- bowel diary
What are complications of constipation?
- pain
- reduced sensation
- fissures
- haemorrhoids
- overflow and soiling
What is GORD?
- reflux through lower oesophageal sphincter into throat and mouth
- immaturity of sphincter in babies
How does GORD present?
- chronic cough
- hoarse cry
- distress after feeding
- reluctance to feed
- pneumonia
- poor weight gain
What systemic signs should raise concern in a vomiting child?
- Respiratory symptoms (aspiration and infection)
- Blood in the stools (gastroenteritis, cow’s milk)
- Signs of infection (fever, lethargy)
- Rash, angioedema, other signs of allergy (cow’s milk)
What associated abdominal and neurological signs are concerning in a vomiting child?
- Abdominal distention (obstruction)
- Reduced consciousness
- Bulging fontanelle
- Neurological signs
(meningitis, raised ICP)
What are vomiting red flags?
- Not keeping down any feed
- Projectile or forceful vomiting
(both pyloric stenosis or obstruction) - Bile-stained vomit
- Haematemesis
(peptic ulcer, oesophagitis, varices)
How is GORD managed conservatively?
- small, frequent meals
- burping regularly
- not over-feeding
- keep baby upright
How can GORD be managed medically?
- gaviscon mixed with feeds
- thickened milk or formula
- PPIs
What are causes of intestinal obstruction?
- meconium ileus
- Hirschprung’s
- oesophageal atresia
- duodenal atresia
- intussusception
- malrotation with volvulus
What is duodenal atresia and what condition is it linked with?
- first part of duodenum is blocked
- Down’s syndrome
- presents a few hours after birth
How is duodenal atresia investigated and what is seen?
- abdo X-ray
- double bubble sign
- confirm with contrast
What is the management of duodenal atresia?
- duodenoduodenostomy
What is meconium ileus?
- small bowel obstruction in CF
- thick sticky meconium
How does meconium ileus present?
- failure to pass meconium within 12-24hrs
- abdo distention
- green bilious vomiting
How is meconium ileus diagnosed?
- abdo X-ray: soap bubble sign
- contrast enema: microcolon and meconium pellets
- DRE: empty rectum
How is meconium ileus treated?
- NG tube to relieve
- contrast enema
- surgery: decompression, resection or ileostomy
What is volvulus?
- torsion of the colon around its mesenteric axis
- leads to compromised blood flow and closed loop obstruction
What is malrotation?
- midgut undergoes abnormal rotation and fixation during embryogenesis
How does malrotation (and volvulus) present?
- feeding intolerance
- abdo pain and constipation
- bloody stools
- bilious vomiting: volvulus
How is malrotation (and volvulus) investigated?
- upper GI contrast study
- USS
How is malrotation (with volvulus) treated?
- surgical intervention: laparotomy
- Ladd’s procedure if volvulus: division of Ladd bands and widening of mesenteric base
- IV fluids if dehydrated
How does intestinal obstruction present?
- persistent, green, bilious vomiting
- abdominal pain and distention
- failure to pass wind or stools
- high pitched, tinkling bowel sounds
How is intestinal obstruction diagnosed?
- abdominal xray
- dilated bowel loops
- absence of air in rectum
How is intestinal obstruction managed?
- paediatric surgical unit
- nil by mouth
- NG tube to drain stomach
- IV fluids
What is cow’s milk protein allergy and what is the epidemiology?
- hypersensitivity to protein in cow’s milk
- affecting <3 years old
- usually outgrown by age 3
What are the two types of cow’s milk protein allergy?
- IgE mediated (within 2hrs)
- Non-IgE mediated (slow over several days)
What factors increase the risk of cow’s milk protein allergy?
- formula feeding
- FHx of atopic conditions
What GI symptoms does cow’s milk protein allergy present with?
- bloating and wind
- abdo pain
- diarrhoea
- vomiting
What general allergic symptoms does cow’s milk protein allergy present with?
- urticarial rash
- angio-oedema
- cough/wheeze
- sneezing
- watery eyes
- eczema
How is cow’s milk protein allergy managed?
- skin prick testing
- avoiding cow’s milk
- breast feeding mothers should avoid dairy
- replace with extensively hydrolysed formula
What is the milk ladder?
- every 6 months can be tried on first step of milk ladder
- malted milk biscuits
- slowly progress up ladder until develop symptoms
What is cow’s milk intolerance?
- presents with same GI features but no allergic features
- outgrow by 2-3 years
- after 1yr can be started on milk ladder
What is acute gastritis?
- inflammation of the stomach
- presents with nausea and vomiting
What is enteritis?
- inflammation of intestines
- presents with diarrhoea
What is gastroenteritis?
- inflammation from stomach to intestines
- presents with nausea, vomiting, diarrhoea
What are differentials for diarrhoea?
- gastroenteritis
- IBD/IBS
- lactose/gluten intolerance
- CF
- medication
What are common causes of viral gastroenteritis?
- rotavirus
- norovirus
- adenovirus
How gastroenteritis caused by E. coli transmitted?
- spread through infected faeces, unwashed salad, contaminated water
What toxin does E.coli produce and what are the symptoms?
- produces shiga toxin
- causes abdo cramps, bloody diarrhoea, vomiting
What is haemolytic uraemic syndrome?
- shiga toxin destroys blood cells
- also caused by use of Abx
Which bacteria commonly causes gastroenteritis?
- E. coli
- campylobacter jejuni
- shigella
- bacillus cereus
What type of bacteria is campylobacter jejuni and how is it spread?
- causes travellers diarrhoea
- gram negative curved/spiral bacteria
- raw/improperly cooked poultry, untreated water, unpasteurised milk
What are the symptoms and treatment of campylobacter jejuni infection?
- abdo cramps, bloody diarrhoea, vomiting, fever
- azithromycin and ciprofloxacin
How does shigella spread and what are the symptoms?
- faeces contaminating drinking water, pools and food
- abdo cramps, bloody diarrhoea, fever
- shiga toxin > haemolytic uraemia syndrome
What toxin does E. coli produce and what symptoms does this lead to?
- shiga toxin
- abdo cramps, bloody diarrhoea and vomiting
- destroys blood cells > haemolytic uraemia syndrome
How is salmonella spread and what are the symptoms?
- raw eggs and poultry
- watery diarrhoea with mucus/blood, abdo pain and vomiting
What type of bacteria is bacillus cereus and on what food is it produced?
- gram positive rod
- inadequately cooked food/food not immediately refrigerated
- fried rice
What toxin does bacillus cereus produce and what symptoms does it cause?
- cereulide
- abdo cramping, vomiting and water diarrhoea
What is giardiasis, what are the symptoms and how is it treated?
- Giardia lamblia is a microscopic parasite spread by faeco-oral transmission
- can be asymptomatic or cause chronic diarrhoea
- treated with metronidazole
How is gastroenteritis managed?
- barrier nursing
- off school for 48hrs
- MC&S
- fluid challenge
What treatment shouldn’t be given in gastroenteritis?
- anti-diarrhoeal
- antiemetic
- Abx only when causative organism identified
What complications might arise from gastroenteritis?
- Lactose intolerance
- Irritable bowel syndrome
- Reactive arthritis
- Guillain–Barré syndrome
What is the pathophysiology behind coeliac disease?
- T-cell mediated: auto-antibodies created in response to gluten exposure, targeting epithelial cells
- anti-tissue transglutaminase and anti-endomysial (IgA)
- affects small bowel, particularly jejunum, causing villus atrophy and malabsorption
How does coeliac disease present?
- failure to thrive
- fatigue
- diarrhoea
- weigh loss
- anaemia 2º to iron, B12, folate deficiency
- dermatitis herpetiformis
What neuro symptoms can coeliac disease cause?
- peripheral neuropathy
- cerebellar ataxia
- epilepsy
Which conditions is coeliac disease associated with?
- T1DM
- thyroid disease
- autoimmune hepatitis
- primary biliary cirrhosis
- primary sclerosing cholangitis
- HLA-DQ2 gene
Which auto-antibodies is coeliac disease associated with?
- tissue transglutaminase (anti-TTG)
- endomysial antibodies (EMAs)
- deaminated gliadin peptides (anti-DGPs)
How is coeliac disease investigated?
- check total IgA to exclude IgA deficiency
- raised anti-TTG
- raised EMAs
What is seen on endoscopy and intestinal biopsy in coeliacs?
- crypt hypertrophy
- villous atrophy
How is coeliac disease managed?
- lifelong gluten free diet
- monitor coeliac antibodies
What is Meckel’s diverticulum?
- congenital abnormality of the GI tract
- outpouching on anti-mesenteric border of ileum
What causes Meckel’s diverticulum?
- incomplete obliteration of the vitelline duct
How does Meckel’s diverticulum present?
- most remain asymptomatic
- ectopic mucosa can cause inflammation and ulceration
- resulting in painless dark red rectal bleeding
- abdominal pain
- intussusception
What is the rule of 2s in Meckel’s diverticulum?
- 2ft proximal to ileocaecal valve
- 2in in length
- 2 types of ectopic tissue: gastric and pancreatic
- 2x more common in males
What are differentials for Meckel’s diverticulum?
- acute appendicitis: periumbilical pain, tenderness, vomiting
- bowel obstruction (can cause)
- gastroenteritis
- peptic ulcer disease
How is Meckel’s diverticulum investigated?
- present acutely with bleeding or diverticulitis
- CT scan
- diagnostic laparoscopy
- nuclear scintigraphy
How is Meckel’s diverticulum managed?
- urgent surgery
- Meckel’s diverticulectomy
- bowel resection if obstruction
What is necrotising enterocolitis?
- disorder affecting premature neonates
- bacterial invasion of intestinal wall
- bowel becomes necrotic and can lead to perforation and shock
What are the risk factors for necrotising enterocolitis?
- v low birth weight
- formula feeds
- resp distress + ventilation
- sepsis
- PDA/CHD
How does necrotising enterocolitis present?
- reduced feeding
- green bilious vomiting
- abdo distention
- bloody stools
- absent bowel sounds
What is seen on bloods in necrotising enterocolitis?
- thrombocytopenia
- neutropenia
- gas: metabolic acidosis
- cultures: sepsis
What is seen on X-ray of necrotising enterocolitis?
- supine abdo X-ray
- dilated bowel loops
- bowel wall oedema
- pneumatosis intestinalis: gas in bowel wall
- pneumoperitoneum: free air in abdomen
- Rigler sign: air outlining bowel
- portal venous gas: air in portal veins
What is the management of necrotising enterocolitis? STAIN
- surgical emergency
- total parenteral nutrition
- antibiotics
- IV fluids
- NBM
