Paeds GI Flashcards
No meconium in 48hrs. Red flag for what?
Hirschprungs
Name an osmotic laxative
lactulose
Name two stimulant laxatives
sodium picosulphate, Senna
Name two stool softeners
Movicol
Klean Prep
When a child has overflow soiling or faecal mass palpable in abdo, it is likely there is faecal impaction. What is a disimpaction regime?
escalating dose of Movicol over 1-2wks
What does Movicol contain?
macrogol + electrolytes. It’s a stool softener
Disampaction regime has been successful! The child no longer has faecal impaction. What’s next?
Maintenance therapy.
After 2 weeks of increasing doses of Movicol, the child is still faecally impacted. What is the next step ?
If Movicol not disimpacted after 2wks, add a stimulant laxative (Senna / sodium picosulphate).
What should you warn families that might happen in the disimpaction regime?
It may initially increase overflow soiling …. and abdo pain
A child who has faecal impaction might leak poo constantly with no feeling. If they are disampacted, they will have the feeling that they need to go. True or false?
True
Child with faecal impaction is undergoing disimpaction regime. However, Movicol is not tolerated. What could you substitute?
A stimulant laxative (e.g. Senna / sodium picosulphate)
Could also add an osmotic laxative (e.g. lactulose)
Right so the child isn’t impacted and now needs maintenance therapy. What does this involve?
ongoing Movicol, adjusting dose to achieve for a type 4/5 poo every day
On disimpaction regime, want to increase the dose until they are having runny type 7s . Then decrease gradualy down to maintenance therapy. On maintenance what kind of poos are we aiming for?
type 4/5 daily
Osmotic laxatives like lactulose are used very frequently in children with constipation. True or false?
False. Movicol and stimulant laxatives always used first.
How long do children need maintenance therapy for? (constipation)
maybe months.
Continue for several wks after regular bowel habit established.
Then reduce the dose over a period of months (don’t stop abruptly)
Do you keep on giving the Movicol when the child has gastroenteritis?
No. Stop it and resume when they are well again.
But if they are just having runny poos this isnt diarrhoea, its just too much Movicol. Dont discontinue just reduce the dose.
If a child has constipation with red flags, do not treat them yet: send to specialist. What are some of the red flags?
- no meconium in 48hrs
- faltering growth
- gross abdo distension
- lower limb deformity (e.g. talipes)
- neuro signs (urinary incontinence, abnormal reflexes)
- signs of spina bifida
- abnormal anorectal anatomy
- perianal fistulae / fissures / abscesses
- perianal bruising (abuse)
How common is idiopathic constipation?
very common!
When is the only time you’d do a digital rectal examination for a constipated child?
if they have red flags, you suspect Hirschsprung, ONLY to be done by a professional competent to interpret the features of Hirschsprungs on DRE
Would you routinely do an AXR to investigate child’s constipation?
NO. Only if obstructed / requested by specialist.
Which blood screens might you do in a child with constipation?
coeliac, TFTs
Most constipation in kids is IDIOPATHIC. Name a few rare PRIMARY causes.
hypothyroidism coeliac Hirschsprungs lower spinal cord problems anorectal abnormalities
How does overflow soiling work?
chronic constipation –> rectum becomes overdistended –> no longer feel need to defecate –> contractions of full rectum overcome internal sphincter –> overflow
What general advice can you give the parents of child with constipation?
balanced diet. sufficient fluids.
non-punitive behavioural interventions - scheduled toileting, rewards (e.g. encourage to sit on toilet after mealtimes, star charts)
What is the difference between suppository and enema?
enema is liquid up rectum
suppository is solid medication up rectum
When would you give an enema to child with constipation?
only when all oral meds have failed
When would you do manual evacuation under anaesthetic in a constipated child?
only when all oral and rectal medications have failed
When all oral and rectal medications have failed in child with constipation, what would you consider?
Manual evacuation under anaesthetic
When a child is having overflow soiling, what is it important that the parents know?
soiling is INVOLUNTARY. Don’t punish and don’t reward for clean pants.
What is the aetiology of Hirschsprungs?
no ganglion cells in myenteric plexus of rectum and colon (spreads variably far up)
What are the findings on DRE in Hirschsprungs?
narrow rectum
stool/flatus GUSH when remove finger
Hirschsprung is usually diagnosed straightaway, when there is no meconium in 48hrs after birth. How can it present later on?
a) few wk old neonate
b) child
a) few wks old - Hirschsprung entercolitis
b) child - chronic constipation, abdo distension, green bilious vomiting, growth failure
What is the gold standard investigation for Hirschsprung???
RECTAL BIOPSY
(the myenteric plexus wouldnt have ganglion cells)
before this, do AXR and maybe contrast enema to find transition zone
The management of Hirschsprung disease if surgical. What are the two steps?
- Colostomy
2. Then ‘pull through procedure’ - cut out dodgy bowel and attach normal bowel to anus.
What is the classical triad of symptoms in Hirschsprung?
failure to pass meconium
abdominal distenstion
bilious green vomiting
Most cases of Hirschsprung’s cases are genetically sporadic (though some complex inheritance). Which sex do they affect most?
males (4:1)
What infective agent commonly causes gastroenteritis in children <2yrs in wintertime? (there is a vaccine for it)
rotavirus
As well as rotavirus, which other viruses cause gastroenteritis in children?
adenovirus
norovirus
Viral gastroenteritis is more common than bacterial gastroenteritis in children. True or false?
true!
Bacterial gastroenteritis is less common than viral in kids. But which bacteria tend be the ones?
campylobacter (painful)
shigella
cholera, E.Coli
Which protozoa can cause gastroenteritis in children?
giardia
cryptosporidium
A child with rapid onset loose watery stools with vomiting. Blood and pus in stools. Is this most likely to be bacterial or viral gastroenteritis?
blood in stools is sign of bacterial (though viral most common)
Gastroenteritis in children. In which scenarios would you take stool sample for miscroscopy, culture and sensitivities?
if blood / pus in stool
if foreign travel
if immuno-compromised
if diagnosis uncertain
Which bacterium causes dysentery?
shigella
Food poisoning and dysentery are notifiable diseases. True or false?
True!
Name some differential diagnoses for gastroenteritis (D+V) in children….
constipation with overflow coeliac cow's milk protein allergy acute appendicitis DKA UTI other inf - sepsis, meningitis, resp, otitis, hepatitis
Which children are particularly at risk from getting dehydrated in gastroenteritis?
infants - particularly LBW
malnourished.
If a child with gastroenteritis has had >6 stools or >3 vomits in the past 24hrs, and hasn’t tolerated any fluids, what are they at risk of?
DEHYDRATION
A child with gastroenteritis has lost <5% of her pre-morbid body weight. Is she clinically dehydrated?
no
<5% loss = no clinical dehydration
A child with gastroenteritis has lost 7% of her pre-morbid body weight. Is she clinically dehydrated?
yes
5-10% loss = clinical dehydration
A child with gastroenteritis has >10% of her pre-morbid body weight. Is she clinically dehydrated?
> 10% loss = SHOCK!
Why is hypernatraemia in dehydration particularly dangerous?
high salt –> water drains out of brain –> cerebral shrinkage –> neuro signs
Give me all the signs of a dehydrated child.
decreased consciousness
decreased urine output
mottled skin cold extremities sunken eyes dry mucus membranes decreased skin turgor
cap refill >2 secs weak peripheral pulses tachycardia tachypnoea hypotension if rlly bad
What often happens to heart rate and respiratory rate in dehydrated child?
tachycardia
tachypnoea
A child has severe dehydration from gastroenteritis. You feel her hands and feet - how do they feel?
cold
Why are infants particularly susceptible to dehydration?
large surface area to volume ratio so more insensible losses
cant ask for water
What bloods would you do for child with gastroenteritis?
U+Es (sodium)
creatinine
glucose
Management of gastroenteritis in children depends on level of dehydration. If there is no clinical dehydration, what is the course of action?
prevent dehydration - encourage fluid intake, with ORS if need be.
A child has gastroenteritis with clinical dehydration. What is the treatment?
oral rehydration solution (maybe via NG).
+ maintenance fluids
+ replace deficit (extra 50ml/kg)
A child with gastroenteritis is in shock from dehydration. What is the treatment?
IV BOLUS
20mls/kg stat 0.9% saline
then maintenance fluid + replace deficit (extra 100ml/kg for shock)
Which bloods do you monitor when treating a child for dehydration ?
U+E (plasma sodium)
creatinine
glucose
Do you use anti-emetics and anti-diarrhoeals to treat gastroenteritis in children?
no!
ineffective, SEs, cost
When would you use antibiotics to treat gastroenteritis in kids?
if specific bac eg cholera
if confirmed sepsis
if immunocompromised
What do you supplement kids with after a bout of gastroenteritis?
zinc! an underrated healer
What is the difference between food allergy and food intolerance?
allergy = pathological IMMUNE response against a specific food PROTEIN
intolerance = non-immunological hypersensitivity reaction
What causes food allergy
pathological immune response against a specific food protein
What causes food intolerance
non-immunological HYPERSENSITIVITY reaction
Name three common food allergies in infants.
milk, egg, peanut
Name two common food allergies in older children.
peanut, shellfish
Some food allergies cause an immediate reaction <2hrs after ingestion - such as urticaria, itch, or facial swelling. What are these called?
IgE mediated
What are the features of Non-IgE mediated food allergies?
diarrhoea, vomiting, abdo pain, faltering growth
Skin prick - drop of allergen on skin, pricked with needle, weal measured. >4mm is positive. If the skin prick is positive, what type of food allergy is it likely to be?
IgE mediated
Non-IgE mediated food allergies are harder to diagnose. Skin prick is likely to be negative. What can you do next?
Try eliminating the food e.g. cows milk. Trial return.
Endoscopy+ biopsy might show eosinophilic infiltrates.
What is the gold standard diagnostic test for both IgE and non-IgE mediated food allergy?
double-blind placebo-controlled FOOD CHALLENGE with resusc available!
What are three ways to manage food allergies?
- avoid said food!
- dietician
- management plans for attacks
What are examples of management plans for attacks for food allergy - a) mild, b) severe
a) antihistamine
b) EpiPen (IM adrenaline)
What is short bowel syndrome?
after large surgical resection of bowel
causes malabsorption, diarrhoea and malnutrition
Name some causes of malabsorption in children?
coeliac, IBD
CF, biliary atresia
short bowel syndrome
a 2yr old has chronic diarrhoea of varying consistency, with undigested veg in it. Otherwise he is well and thriving. What is the likely diagnosis and prognosis?
Toddler’s diarrhoea
improves with age
Which boys does pyloric stenosis specially affect?
FIRST BORN BOYS with FHx = pyloric stenosis!
What is the pathophysiology of pyloric stenosis?
hypertrophy of the pyloric muscle –> gastric outlet obstruction
Which age group does pyloric stenosis affect?
2 - 8 wks
Why can pyloric stenosis cause metabolic alkalosis?
losing HCl from stomach
Why can pyloric stenosis cause low sodium and low potassium?
losing stomach contents
When does the projectile vomiting occur in pyloric stenosis?
straight after feeding! ouch
As well as projectile vomiting, what are three other symptoms of pyloric stenosis?
hunger
dehydration
weight loss
What would an ABG show in pyloric stenosis?
metabolic alkalosis (hypochloraemic)
What are three investigations for pyloric stenosis?
Test Feed
Ultrasound
ABG
What happens in a “test feed” for pyloric stenosis?
give dioralyte, see visible peristaltic wave. + palpable pylorus
What is the treatment for pyloric stenosis (three stages)?
stop feeding.
IV fluids and correct electrolytes.
“pyloromyotomy”
What is the surgery used to treat pyloric stenosis?
Ramstedt’s pyloromyotomy
An infant has paroxysmal inconsolable crying, drawing up knees to pass flatus. What is this likely to be?
infant colic
How long does infant colic usually take to resolve?
12 months. Reassurance.
*if it persists, think about CMPA or GORD
What is posseting?
When babies regurgitate a small amount of milk and air shortly after feeding
Proper regurgitating is larger and more freq
Whereas vomiting is forceful ejection of gastric contents.
Red flags for the vomiting child are either about the character of the vomiting, or about what other symptoms the vomiting goes along with. Give me three red flags about the character of the vomiting.
- green bilious vomit
- haematemesis
- projectile
RedFlagVomiting: If the vomit is green bilious, it’s obstruction. Where is the obstruction?
below the sphincter of Oddi
Red flags for the vomiting child include green bilious vomit, haematemesis, and projectile vomiting. Certain symptoms IN ADDITION to vomiting can also be red flags. Name some of these :)
Vomiting, plus \+ abdo pain/distension \+ hepatosplenomegaly \+ blood in stool \+ seizures / bulging fontanelle \+ faltering growth \+ dehydration / shock
RedFlagVomiting: If a child has vomiting plus dehydration/shock, what two important things should you think of?
infection (gastroenteritis or systemic)
DKA
RedFlagVomiting: If a child has vomiting plus blood in the stool, what should you think of?
bacterial gastroenteritis
intussusception
RedFlagVomiting: If a child has vomiting plus seizures / bulging fontanelle, what should you think of?
raised ICP
RedFlagVomiting: If a child has vomiting plus faltering growth, what should you think of?
coeliac, GORD, food allergy
Number one cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years?
Meckel’s diverticulum
When does weight count as ‘faltering’?
crosses two centile lines, OR
drops below 0.4th centile, OR
BMI drops below 2nd centile.
There are 5 categories of causes of weight faltering. What are they love?
- inadequate intake
- malabsorption
- inadequate retention
- failure to utilize nutrients
- increased requirements
The first three causes of weight faltering are:
- inadequate intake
- malabsorption
- inadequate retention
what are the other two causes?
- failure to utilize nutrients
5. increased requirements
If a child is miserable, with distended abdo and thin buttocks, what does this make you think of?
malabsorption
The first cause of weight faltering is inadequate intake. This can be environmental or pathological. Give some environmental causes of inadequate intake.
- bad availability of food (e.g. no regular feeding times, incorrect formula, can’t afford)
- psychosocial deprivation (e.g. poor maternal ed)
- child abuse (deliberate underfeeding)
The first cause of weight faltering is inadequate intake. This can be environmental or pathological. Give some pathological causes of weight faltering.
- impaired suck/swallow
- severe GORD
- anaemia of chronic illness
Why might a child have impaired suck/swallow?
cleft palate
cerebral palsy
The second cause of weight faltering is malabsorption. Can often see with distended abdo, thin buttocks, misery. Throw out some diseases that malabsorption in kids.
short gut syndrome
post-NEC
liver disease
IBD, cows milk protein allergy, CF, coeliac
The third cause of weight faltering is inadequate retention. Give me 2 reasons for inadequate retention.
vomiting
severe GORD
The fourth cause of weight faltering is failure to utilize nutrients. What are a few reasons for failing to use nutrients properly? (all congenital)
Down’s
extreme prematurity / IUGR
metabolic storage disorders
The fifth cause of weight faltering is increased requirements. This can be the case in chronic resp or kidney disease, as well as……..four others!!
Thyrotoxicosis!
Malignancy!
Chronic infection! (HIV)
Congenital heart disease!
How do thyrotoxicosis, malignancy, chronic infection, and congenital heart disease cause weight faltering??
INCREASED REQUIREMENTS.
Have a think about all the things that could be causing weight faltering. Name me a few of the many BLOODS you might check.
FBC, WCC, CRP, U+Es, creatinine, Ca + phos, ferritin, TFTs, LFTs, IgA tTG, immunoglobulins
The management of weight faltering obvs depends on the underlying cause. They are managed mostly in primary care. Name some professionals who might be involved.
health visitor
PAED DIETICIAN
SALT
clinical psych / social services
Name some DIETARY strategies for increasing intake…
more variety
more enrgy density
less milk + fruit juice
3 meals + 2 snacks
Name some BEHAVIOURAL strategies for increasing intake…
regular mealtimes
eat together
avoid conflict
praise when eaten ignore when not
