Paeds - GI Flashcards
what is GORD?
gastro-oesophageal reflux disease - when there is the inappropriate effortless passage of gastric contents into the oesophagus
what are the causes of reflux in infancy?
it is associated with slow gastric emptying, liquid diet, horizontal position, and low resting lower oesophageal sphincter pressure.
lower oesophageal sphincter dysfunction (hiatus hernia) may cause reflux increased gastric pressure external gastric pressure gastric hypersecretion of acid food allergy cerebral palsy
what age group is GORD common in?
common in the first 5 years of life but usually all symptoms clear by 12 months.
how does GORD present?
regurgitation non-specific irritability cough hoarseness stridor lower respiratory disease - aspiration pneumonia, asthma dystonic neck posturing
what are the complications of GORD?
oesophageal stricture barrett's oesophagus faltering growth anaemia lower resp disease
how is GORD managed in children?
usually diagnosed clinically
nuse infants on a head up slope of 30 degrees
thicken milk feeds in infants, small frequent meels, avoid food before sleep, avoid fatty foods, cirtus juices, caffeine and fizzy drinks
add drugs if severe - ranitidine or omeprazole
what causes pyloric stenosis in children?
idiopathic hypertrophic pyloric stenosis
hypertrophy of the pylori muscle causing outlet obstruction
when does pyloric stenosis usually present?
usually in the third or fourth week of life
** it is more common in boys
what is the presentation of pyloric stenosis in infants?
projectile vomiting, non-bilious, may contain altered blood (coffee ground) or fresh blood from oesophagitis. Vomiting will occur within an hour of feeding and the baby is immediately hungry. If they present early (2nd/3rd week) then vomiting may not be projectile.
weight loss
constipation
dehydration, malnutrition and jaundice are late sings
palpable mass in the upper abdomen
what tests would you perform to diagnose pyloric stenosis?
test feed - peristalsis seen during feed, the pyloric tumour is usually easiest felt early in the feed or after the baby has vomited
US - if tumour cannot be felt, USS will confirm or exclude the diagnosis
biochemistry - hypochloraemic, hypokalaemic metabolic alkalosis
how is pyloric stenosis managed in children?
rehydrate and correct the alkalosis before surgery
IV fluids
withold feeds - the stomach should be emptied with an NGT
Ramsteds’s pyloromyotomy
what is crohn’s disease?
it is a type of inflammatory bowel disease that may affect any part of the GI tract but terminal ilium and proximal colon are commenest sites of involvement
bowel involvement is non-continuous (skip lesions)
how does crohns disease present?
abdominal pain diarrhoea +/- blood/mucus weight loss lethary fever oral lesions perianal skin tag uvitis erythema nodosum
what investigations woud you perform for crohns disease?
FBC - anaemia may be present, leukocytosis is associated with acute or chronic inflammation, thrombocytosis is a useful marker for active inflammation
iron studies, B12, and folate
there may be hypoalbuminaemia, hypocholesterolaemia, and hypocalcaemia
raised ESR and CRP
stool samle - to rule out and infectious cause
endoscopy
CT or MRI - helps to localise disease
how do you treat crohns disease?
mildly active disease
- observation with monitoring or budesonide
moderately active disease
- budesonide and/or 5-ASA, secondary option prednisolone. Antibiotics can be added if septic complications are suspected
- 2nd line - immunomodulator therapy - azathioprine
in moderate to severe disease oral prednisolone or IV methylprednisolone can be used to induce remission
antibitoics - ciprofloxacin or metronidazole can also be useful
infliximab may be usuaful if conventional treatments dont work
surgical management: local surgical resection for severe localised disease e.g. strictures, fistula, may be indicated
what is ulcerative colitis?
a form of inflammatory bowel disease, inflammation always starts at the rectum and never spreads beyod the ileocaecal valve and is continuous.
what is the presentation of UC?
bloody diarrhoea urgency tenesmus abdominal pain, particularly in the lower left quadrant weight loss growth failure
in children it is usually pancolitis where as in adults it is usally confined to the distal colon
how is UC managed?
amino salicylates are used to induce remession (mesalazine)
oral corticosteroid can also be used
more agressive disease may need immunomodulator therapy (azathioprine) to remain remession
if severe - manage in hospital
*methotrexate is not reccomened in UC
how is UC diagnosed?
colonoscopy biopsies stool studies FBC ESR CRP barium enema - will show loss of haustrations, superficial ulceration and in long-standing disease - the colon is narrow and short
what are the viral causes of gastroenteritis?
rotavirus (most common)
caliciviruses (norovirus and sapovirus)
adenovirus
astrovirus
what is the presentation of gastroenteritis?
vomiting non-bloody diarrhoea cramping abdominal pain low grade fever dehydration
what are the risk factors for dehydration in gastroenteritis?
- infants under the age of 6 months or those born with a low birth weight
- if they have passed more than 6 diarrhoeal stools in the previous 24 hours
- if they have vomited three times of more in the past 24 hours
- if they have been unable to tolerate/not been offered extra fluids
- if they have malnutrition
what are the different classifications of dehydration?
mild: (less than 5% loss of body weight): skin turgor may be dcreased, dry mucous membranes, low urine output, HR increased, BP normal, perfusion normal, pale, may be irritable
moderate: (5-10% loss of body weight): skin turgor decreased, very dry mucous membranes, oliguric, HR increased, BP may be normal, prolonged cap refil, grey skin colour, lethargic
severe: (10-15% loss of body weight): poor skin turgor with tenting, parched mucous membranes, anuric, increased HR, BP decreased, prolonged cap refil, mottled skin, comatose
what are the red flag signs of hypovolaemic shock?
appears unwell or deteriorating, altered responsiveness, tachycardia, tachypnoea, skin turgor reduced
what is isonatraemic and hyponatraemic dehydration?
Isonatraemic - losses of sodium and water are proportional and the plasma sodium levels remains within a normal range
hyponatraemic - if the child with diarrohea drinks large quantities of water, it leads to a fall in plasma sodium - this leads to a shift of water from extra cellular to intracellular compartments which increases cellular volume - may result in convulsions
what is hypernatraemic dehydration?
water losses exceeds the relaitve sodium loss and the plasma sodium concentration increases
the extracellular fluid becomes hypertonic with respect to intracellular fluid and this leads to a shift of water into the extracellular space from the intracellular compartments
this form of dehydration is hard to see as there is not signs of extracellular fluid delpetion.
This type of dehydration occurs when there is high insensible water loss (when water is lost through the skin - high fever or hot dry enviroment) or from perfuse, low sodium diarrhoea.
water is drawn out of the brain and cerebral shrinkage within rigid skull may lead to jittery movement, increased muscle tone with hyperreflexia, altered consciousness, seizures and multiple small cerebral haemorrhages
how do you treat viral gastroenteritis?
fluids - oral rehydration solution
mild dehydration - less than 5% loss of body weight give 50mls/kg plus maintenance fluids
moderate (less than 10%) - 100ml/kg plus maintenece
if shock add fluid bolus
what are some common causes of bacterial gastroenteritis?
it is most common in children under 2
salmonella campylobacter jejuni shigella E. coli clostridium difficile Bacillus cereus
sources of infection include contaminated water, poor food hygiene, faecal-oral route
what is the presentation of bacterial gastroenteritis?
watery diarrhoea vomiting cramping abdo pain fever dehydration electrolyte disturbance malaise blood and mucus in diarrhoea abdo pain may mimic appendicitis or IBD tenesmus
what are the complications of bacterial gastroenteritis?
bacteraemia secondary infections - pneumonia, osteomyelitis, meningitis Reiter's syndrome GBS haemolytic-uraemic syndrome reactive arthropathy haemorrhagic colitis
what investigations would you perform for bacterial gastroenteritis?
stool +/- culture
stool clostridium difficile toxin
sigmoidoscopy
what are the classical symptoms of appendicitis?
anorexia
abdominal pain - initially central but localises to the RIF
low-grade fever
nausea
diminished bowel signs
*younger children or children with a retrocaecal/pelvic appendix may present atypically
it is uncommon in children under the age of 4 - however if these children do get it, it often presents when perforated
what investigations would you order for appendicitis?
FBC - mild leukocytosis (increase in WCC)
pelvic or abdominal CT
USS
urinalysis - to rule out other causes
how do you treat appendicitis?
appendectomy plus supportive care
IV antibiotics - cefoxitin
what is a congenital diaphragmatic hernia?
it is characterised by the herniation of abdominal viscera into the chest cavity due to incomplete formation of the diaphragm - this can result in pulmonary hypoplasia and hypertension which can cause respiratory distress shortly after birth
what is the most common type of congenital diaphragmatic hernia?
left-sided posterolateral Bochdalek hernia (85%)
- there is left sided herniation of abdominal contents through the posterolateral foramen of the diaphragm
on physical examination what signs would you find suggesting a congenital diaphragmatic hernia?
the apex beat and the heart sounds will be displaced to the right side of the chest wall, with poor air enrty to the left side
