Paeds GI Flashcards
CASE
A baby who keeps vomiting
O/E - looks fine, putting weight on well
Diagnosis?
GORD
What is the pathophysiology of vomiting in GORD?
Functional immaturity of the oesophageal sphincter
Lying down loads (cause they’re a baby)
Predominantly liquid food
Short intra-abdominal length of the oesophagus
What are the risk factors for developing GORD?
Cerebral palsy
Pre-term - especially if broncho-pulmonary dysplasia
After surgery for oeseophageal atresia or diaphragmatic hernia
How would you investigate a baby with GORD?
Clinical diagnosis basically
But then if they fail to respond to treatment or complications - oesphageal pH monitoring (degree of acid reflux) and endoscopy + oesophageal biopsies for oesphagitis + other causes
How would you treat a baby with mild GORD?
Reassurance
Add thickening agent to feeds
Small frequent meals
Avoid food before sleep
Avoid fatty foods, citrus, caffeine, carbonated drinks
Position with head at 30 degrees prone after feeds
How would you treat a child with significant GORD?
H2 receptor antagonist eg Ranitidine
PPI eg omprazole
If complications - Nissen fundoplication
What are the complications of GORD?
Oesophageal stricture Oesophagitis Recurrent pulmonary aspiration Barrett's oesophagus Failure to thrive Anaemia
CASE
Baby that is vomiting after feeds, is getting worse and is now projectile
Differentials?
Pyloric stenosis
Really bad GORD
Obstruction - malrotation
Duodenal atresia
What would you see in the bloods of a patient with pyloric stenosis / recurrent vomiting?
Hypochloraemic, hypokalaemic metabolic acidosis
So low chloride, potassium (and sodium)
And low bicarb, low base excess, low pH and probably low CO2 cause of respiratory compensation
How would you investigate a baby with suspected pyloric stenosis?
Immediate resuscitation if needed ABG Test feed Visible gastric peristalsis - left to right Palpable OLIVE SHAPED MASS in the RUQ
What could you do to help you to examine (with palpation) a baby with pyloric stenosis?
Feed - milk calms a hungry baby
NG tube to get rid of air in the stomach if its overdistended
How would you manage a child with pyloric stenosis?
Rehydration - 0.45% saline and 5% dextrose and potassium supplementation
Pyloromyotomy - feed after 6 hours, discharge after 2 days
What are the symptoms and signs of appendicitis?
Abdominal pain - colicky, initially central and then localised to RIF
Anorexia
Vomiting
Flushed face Oral fetor Low grade fever Abdo pain worse on movement Tenderness and guarding at McBurney's point
How would you investigate a child with suspected appendicitis?
Bloods - neutrophilia
USS to exclude other things
CT
Laparoscopy
What might you see on abdominal X ray in a child with appendicitis?
Faecoliths
How would you manage a child with suspected appendicitis?
Nil by mouth
Appendicectomy - usually laporoscopic
How would you manage a child with a perforated appendix?
Fluid resus
IV metronidazole before surgery
CASE
A 1 year old with episodes of abdominal pain, vomiting and some blood stained mucous in the their nappy
Differentials
Intusussception
What are the symptoms and signs of intussusception?
PAIN - paroxysmal, colicky - drawing up of legs, lethargy between episodes
VOMITING - can be bile stained
Sausage shaped MASS in RUQ
REDCURRANT JELLY
Abdo distension
Shock
How would you investigate a child with redcurrant jelly stool?
Examination - sausage shaped stool
Rectal exam - blood
AXR - small bowel obstruction, soft tissue mass
USS - target sign
What would you see on an abdominal X ray in a child with small bowel obstruction?
Distended small bowel
Absence of air in distal colon and rectum
What is intussusception?
Invagination of proximal bowel into distal (telescoping)
Where does intussusception commonly occur?
Ileo-caecal valve
How would you manage a child with intussusception?
ABCDE
IV fluids
Analgesia
NG tube if vomming
Radiological reduction of intussusception - by rectal air insufflation
What are the risks associated with the procedure to reduce an intussusception?
Perforation
Incomplete reduction
What are the complications of intussusception?
Bowel perforation
Peritonitis
Gut necrosis
CASE
A child with profuse fresh rectal bleeding
Diagnosis?
Meckel’s diverticulum
What is Meckel’s diverticulum?
Ileal remnant of the vitello-intestinal duct
Give some features of Meckel’s diverticulum
RULE OF 2s 2% of the population Age presentation before 2 2 inches long Within 2 feet of the ileo-caecal valve 2 types of tissue - gastric and pancreatic
What are the complications of Meckel’s diverticulum
Severe rectal bleeding
Intussusception
Volvulus
Diverticulitis - mimics appendicitis
How would you diagnose Meckel’s diverticulum?
Technetium scan - shows increased uptake by gastric mucosa tissue
When and how would you treat a child with a Meckel’s diverticulum?
If symptomatic
Laparoscopic resection
CASE
A 2 day old baby presents with dark green vomiting
Diagnosis?
Obstruction - somewhere below the level of the bile duct
In this age group - usually malrotation
How would you investigate a child with bilious vomiting?
Urgent upper GI contrast study
What is malrotation?
Mesentery not fixed at the duodenojejunal flexure or ileocaecal region - volvulus during rotation of the small bowel in foetal life
If Ladd bands (fibrous bands attaching caecum to retroperioneum in RLQ) cross the duodenum - bowel obstruction
How would a child present with malrotation?
Dark green vomiting - bilious
Abdominal pain + tenderness - peritonitis or ischaemic bowel
How would you diagnose malrotation>
Upper GI contrast study
If signs of vascular compromise - urgent laparotomy
How would you treat a child with malrotation?
ABCDE
Fluid resuscitation
Surgery (urgent) to untwist the volvulus
+ generally remove the appendix to avoid diagnostic confusion if they later present with signs of appendicitis
