Paeds GI, nutrition and genitourinary (ILA 4) Flashcards
Define possetting
non forceful return of small amounts of milk which is often accompanied by the return of swallowed air “wind”
Define regurgitation
non forceful return of large amounts
Define vomiting
forceful ejection of gastric contents
List the differentials for vomiting in an infant
colic **
GORD **
feeding problems
gastroenteritis or any infection
dietary problems e.g. cows milk protein intolerance
intestinal obstruction - pyloric stenosis, atresia, intussusception, volvulus, Hirschprungs
List the differentials for vomiting in a pre school child
gastroenteritis infection e.g. UTI, meningitis coeliac disease appendicitis intestinal obstruction torsion of testes renal failure
List the differentials for vomiting in a school age/ adolescent child
gastroenteritis infection e.g pyelonephritis, sepsis, meningitis crohns, ulcerative colitis coeliac disease appendicitis bulimia/ anorexia pregnancy migraine renal failure DKA
Outline the red flags to identify in a vomiting child
signs of dehydration
weight loss / faltering growth
bile stained
haematemesis
abdominal tenderness and distension
blood in stool
bulging fontanelle, seizures
projectile vomiting
List the signs of dehydration
tachycardia tachypnoea dry mucuous membranes reduced skin turgor decreased urine output irritable, lethargic sunken eyes
List the signs of hypernatraemic dehydration
jitteriness increased muscle tone hyper reflex drowsiness convulsions
How is dehydration managed?
50 ml/kg of low osmolarity rehydration solution over 4 hours
plus ORS solution for maintenance
continue breastfeeding
What is the normal frequency of defection in a child depending on their age?
first few weeks of life -> 4 stools per day
1 year old -> 2 per day
breast fed infants -> common not to pass stools for several days
> 3 y/o -> same as adults -> 3 stools per day to 3 stools a week
List the causes of constipation
idiopathic constipation **
dehydration low fibre in diet drugs e.g. opiates problems with toilet training stress
babies… hirschprungs disease, anorectal abnormalities, hypothyroidism, hypercalcaemia
How can constipation present and what would you look for in the history?
- STOOL PATTERN
<3 complete stools per week - SYMPTOMS WITH DEFAECATION
distress, straining, blood with stool, pain, poor appetite that improves on passing stool - HISTORY
previous constipation, previous anal fissure
identify the red flag clinical features of constipation
failure to pass meconium in first 24 hours of life -> Hirschsprungs
faltering growth -> hypothyroidism, coeliac
abdo distension -> Hirschsprungs
abnormal lower limb neurology
How is constipation managed?
- behavioural - toileting routine, star charts, bowel habit diary
- diet and lifestyle - increase fluid intake and fibre intake
- laxatives 1st line = Movicol paediatric plain (if fails to work after 2 weeks, add Senna a stimulant)
- maintenance laxatives until regular bowel movements 1st line = Movicol
List the surgical causes for acute abdominal pain
acute appendicitis inguinal hernia meckel diverticulum pancreatitis trauma interssusception intestinal obstruction
List the medical causes for acute abdominal pain
gastroenteritis UTI hence schonlein purport DKA hepatitis constipation inflammatory bowel disease psychological
Define recurrent abdominal pain?
pain sufficient to interrupt normal activities and lasts for >3 months
List the differentials for recurrent abdominal pain
UNKNOWN
GI - crohns, ulcerative colitis, constipation, gastritis, peptic ulcer, IBS, malrotation
GYNAE- endometriosis, dysmenorrhoea, PID, ovarian cysts
PSYCHOLOGICAL- stress, bullying, abuse
URINARY TRACT- UTI, hepatitis, gall stones, pancreatitis
How is recurrent abdominal pain managed?
- identify any serious causes without multiple investigations e.g. urine microscopy, ultrasound
- full history and examination
- reassure parents
What is Gastro-Oesophageal reflux disease?
involuntary passage of gastric contents into the oesophagus
caused by inappropriate relaxation of the lower oesophageal sphincter as a result of functional immaturity
How does GORD present?
recurrent regurgitation ** = non forceful regurgitation of large volumes of milk
well child
dry cough
unhappy lying flat , crying after feeds
Who does GORD most commonly affect?
very common in infancy, usually resolved by 12 months old
Outline the possible complications of GORD
failure to thrive
oesophagitis
pulmonary aspiration
dystonic neck posturing
How is GORD managed conservatively, medically and surgically?
- add thickening agent e.g. Nestargel to feeds
- add 1-2 trial of Gaviscon (alginate therapy) to feeds + smaller more frequent feeds, position head up after feeds
- add PPI or H2 receptor antagonist to feeds
How is pyloric stenosis caused?
hypertrophy of the pyloric muscle causing gastric outlet obstruction and impaired gastric emptying
Describe the classic presentation of pyloric stenosis
present at 2-7 weeks of age most commonly boys projectile vomiting (non bilious) hunger after vomiting weight loss dehydration
Which metabolic changes would you expect to see in a child with pyloric stenosis?
metabolic alkalosis
hypokalaemia
hyponatraemia
hypochloraemia
Which investigation confirms a diagnosis of pyloric stenosis?
ultrasound
How is a baby with pyloric stenosis assessed?
- gastric peristalsis
- pyloric mass felt - like an “olive”
- ultrasound** - confirm diagnosis
- dehydration
How is pyloric stenosis managed?
- IV fluids, correct electrolyte imbalance
2. pyloromyotomy “ramstedts procedure”
What are the symptoms and signs of acute appendicitis?
abdominal pain - initially central/colicky and then localises to RIF (Mcburneys point) fever vomiting anorexia persistent tenderness
Outline the necessary investigations for acute appendicitis
- raised CRP and raised WCC
2. ultrasound
How is acute appendicitis managed?
appendicectomy!!!1
if suspect perforation, IV fluids and IV antibiotics
What is interssusception?
“telescopic bowel”
invagination of the proximal bowel into a distal segment
most common is ileum passing into caecum through the ileocaecal valve
Describe the common presentation of interssusception
age 3 months - 2 years old , more common in boys
few days history of severe colicky pain - draw knees in and pale
intermittent screaming with lethargy in between
**red currant jelly stool **
billious vomiting
What would you expect to find on examination of a child with interssusception?
sausage shaped mass palpable in RLQ**
abdominal distension
How is interssusception diagnosed?
ultrasound * - doughnut, target sign , “alternating echogenic and hypoechogenic rings”
How is interssusception managed?
- ABC
- fluid resus and alert HDU
- surgery - rectal air insufflation
What is meckels diverticulum?
ill remnant of the vitello intestinal duct
can contain ectopic gastric mucosa or pancreatic tissue
How is meckels diverticulum remembered?
RULE OF 2…
2 feet from ileo-caecal valve
2% of population
2cm long
(presents with rectal bleeding and anaemia)
How is meckels diverticulum managed?
- technetium scan
2. surgical resection
What is the most common viral cause of gastroenteritis?
rotavirus infection (60%)
List the bacterial causes of gastroenteritis?
campylobacter jejuni infection - abdo pain, most common
shigella - blood in stool, tenesmus
salmonella - blood in stool, tenesmus
cholera - profuse, watery, rapidly deteriorating
E.coli - profuse, rapidly deteriorating, most common cause of traveller diarrhoea
staph aureus- cause acute food poisoning, resolves in 2 days
How might gastroenteritis present?
loose/watery stools vomiting abdominal pain (Campylobacter) dehydration history of travel abroad/ contact with someone with diarrhoea
Which symptoms would suggest a shigella or salmonella cause of gastroenteritis?
blood and pus in stool
high fever
tenesmus
How is dehydration measured during diarrhoeal illness?
dehydration measured by degree of weight loss..
<5% weight loss = no dehydration clinically
5-10% weight loss= clinically dehydrated
>10% weight loss= shock
How is gastroenteritis managed?
- no investigations necessary - stool culture if blood/ septic child
- fluids and rehydration solutions
- monitor nutrition
What is Hirschprungs disease?
absence of ganglionic cells from myenteric plexus of large bowel
due to developmental failure of the parasympathetic Auerbach and Meissner plexuses
How does Hirschsprungs disease present?
failure to pass meconium within 48 hrs of life
constipation
abdominal distension
bilious vomiting later
How is hirschsprungs disease diagnosed?
suction rectal biopsy
How is hirschsprungs disease managed?
- rectal washout and enema
2. surgical resection
What is intestinal malrotation?
obstruction of the small bowel
congenital anomaly of rotation of the midgut
if a few day old child presents with billious vomiting, what must be ruled out?
INTESTINAL MALROTATION
How does intestinal malrotation present?
billious vomiting
1-7 days old child
abdominal pain
(if this is presentation, must rule this out!)
How is intestinal malrotation diagnosed?
upper GI contrast study =1st line and diagnostic
How is intestinal malrotation treated?
surgical correction by Ladds procedure
When is chronic diarrhoea (Toddlers diarrhoea) suspected?
stools varying in consistency e.g. explosive, loose or formed
children well and thriving
no precipitating dietary factors
grow out of symptoms by 5 y/o
How is coeliac disease caused?
gliadin in gluten causes a immunological response in the proximal small intestine to cause shorter villi and flat mucosa
What is associated with coeliac disease?
family history
autoimmune diseases e.g. type 1 diabetes, hypothyroidism, graves, psoriasis, SLE
Which gastrointestinal symptoms are seen with coeliac disease and when do they present?
present at 8-24 months of age AFTER introduction of wheat containing food…
diarrhoea/ malabsorptive stools
abdominal distension and bloating
failure to thrive
buttock wasting
Outline other multi system symptoms and signs of coeliac disease
anaemia - iron or folate deficiency growth failure dermatitis herpetiformis hyposplenism osteomalacia mouth ulcers
What is the diagnostic sign of coeliac disease?
IgA tissue transglutaminase antibodies
How is coeliac disease managed?
remove gluten from the diet!!
avoid wheat, barley, rye and symptoms will resolve
Describe the pathology of crohns disease
granulomatous inflammation of the distal ileum and proximal colon
transmural
normal bowel areas in between areas of diseased areas
‘cobblestone appearance”
Describe the classic presentation of crohns disease
abdominal pain diarrhoea lethargy and fatigue weight loss growth failure/ delayed puberty
List the extra intestinal manifestations of crohns disease
erythema nodosum iron deficiency anaemia uveitis perianal skin tags arthralgia conjunctivitis clubbing mouth ulcers
How is crohns disease investigated?
- endoscopy and biopsy
- raised CRP and ESR
- small bowel imaging
How is crohns disease managed medically?
- immunosuppressant medication e.g. aziothioprine, methotrexate - to maintain remission
- long term supplemental enteral nutrition
if treatment fails, anti-tif agents e.g. infliximab or surgery
What is ulcerative colitis?
recurrent inflammation and ulceration of the mucosa of the colon
extends from rectum proximal
continuous diseases
crypt damage - abscess, loss of crypts
How does ulcerative colitis present?
colicky pain diarrhoea weight loss rectal bleeding growth failure
In ulcerative colitis, what are you at increased risk of?
adenocarcinoma of the colon
so need regular colonoscopic screening
How is UC investigated?
endoscopy and colonoscopy and biopsy
widespread ulceration, pseudopolyps, crypt abscesses
How is UC managed depending on severity of disease?
mild = aminosalicylates e.g. mesalazine
aggressive = systemic steroids for acute attacks and immunomodulatory therapy for remission (azathioprine)
severe = colectomy with ileostomy
List of the causes of nutrient malabsorption
biliary atresia lymphatic leakage short bowel syndrome - necrotising enterocolitis crohns / UC cystic fibrosis coeliac disease lactose intolerance
What is cows milk protein allergy associated with?
atopy
IgA and IgG deficiency
What are the symptoms of cows milk protein allergy?
loose stools vomiting failure to thrive atopic history GORD
If the stools are bloody with cows milk protein allergy, what would be suspected?
cows milk protein colitis
How is cows milk protein allergy managed?
- eliminate from diet - if symptoms improve then diagnose
- hydrolysed feeds
- amino acid based feeds
what is the difference between hydrolysed feeds and amino acid based feeds?
hydrolysed feeds = break the milk protein up into pieces
amino acid based feeds = made with individual amino acids so well tolerated
How does lactose intolerance present and who it is associated with?
associated with oriental backgrounds
explosive watery stools
abdominal distension
audible bowel sounds
flatulence
How is lactose intolerance diagnosed?
- lactose hydrogen breath test
2. eliminate from diet
How is lactose intolerance managed?
- eliminate lactose from diet
- lactose free formula and milk free diet
- calcium and vitamin D supplements
How long does WHO recommend mothers breast feed for?
6 months
What are the advantages of breastfeeding?
reduces incidence of necrotising enterocolitis in preterm babies
helps with bonding/ loving relationship
reduces breast cancer risk in women
reduced incidence of obesity, diabetes and hypertension in babies
passive immunity
What are the limitations of breastfeeding?
puts pressure on mother if fail to establish feeds
restrictive for mother
cannot tell how much a baby is taking from breast
difficult for preterm babies
transmission of infection and drugs e.g. HIV, hep B, CMV
vitamin K deficiency
Describe the physiology of breast feeding
- baby uses rooting, sucking and swallowing reflexes to feed
- hypothalamus sends impulses to pituitary gland
- anterior pituitary secretes prolactin which stimulates milk production in acini of breast
- posterior pituitary secretes oxytocin which contracts myoepithelial cells in alveoli, forcing milk into larger ducts
List some of the properties of breast milk
IgA bifidus factor lysozyme lactoferrin macrophages lymphocytes protein calcium phosphorus
When is pasteurised cows milk given to a child?
at 1 years old
When should specialised formula be used?
cows milk protein allergy
lactose intolerance
cystic fibrosis
neonatal cholestatic liver disease
When should weaning start?
solid foods recommended to be introduced at 6 months of age
start with pureed fruit, root vegetables or rice
Define “faltering growth”
“dropping centiles” - either growth faltering or weight faltering
fall across 1+ centiles if <9th gentile at birth OR
fall across 2+ centiles if 9th-91st centile at birth OR
weight under 2nd gentile regardless of birth weight
Outline the possible causes of failure to thrive
FEEDING PROBLEMS
ineffective suckling in breast fed infants
ineffective bottle feeding
post natal depression
insufficient food/ quantities of milk offered
NON ORGANIC
neglect/ abuse
psychosocial deprivation
ORGANIC
suckling - cleft palate, cerebral palsy
vomiting - GORD
malabsorption - coeliac, cystic fibrosis
increased requirements - HIV, congenital heart disease, thyrotoxicosis
How is faltering growth assessed?
- growth and weight chart
- examination for any organic illness
- history of diet, feeding, development
What are the possible causes of diarrhoea in children?
inflammatory bowel e.g. crohns, UC coeliac disease chronic constipation side effects of antibiotics gastroenteritis bowel obstruction toddler diarrhoea cows milk intolerance hyperthyroidism
List the anomalies of the urinary tract detectable during antenatal ultrasound screening
renal genesis multicystic dysplastic kidneys polycystic kidney disease horseshoe kidney / pelvic kidney duplex system bladder extrophy urine flow obstruction
How is polycystic kidney disease inherited?
autosomal dominant
What complications can polycystic kidney disease cause?
haematuria renal failure hypertension cysts in the liver and pancreas cerebral aneurysms mitral valve prolapse
Where can urine flow obstruction occur?
pelvicouteric or vesicoureteric junction
bladder neck
posterior urethra
What are the consequences of urine flow obstruction?
thickened bladder wall
hydronephrosis
bladder neck obstruction
What does Potter syndrome result from?
multi cystic dysplastic kidneys
bilateral renal genesis
How does potter syndrome manifest?
primary problem is kidney failure causing reduced fetal urine excretion and oligohydramnios
causes facial features of low seat ears, beaked nose and lung hypoplasia
Which investigations are carried out to assess renal function
- plasma creatinine concentration
- estimated glomerular filtration rate - good measure of renal function
- EDTA GFR
- creatinine clearance
- plasma urea concentration - raised levels are symptomatic
Which radiological investigation if preferred to assess renal anatomy?
ultrasound
shows anatomy, urinary tract dilatation, stones, nephrocalcinosis
What are the most common causative organisms of an UTI?
E.coli ***
Pseudomonas
Proteus
Klebsiella
What are the risk factors for an UTI?
urinary tract abnormality
incomplete bladder emptying e.g. infrequent voiding, incomplete micturition, constipation
vesicoureteric reflux
What is vesicoureteric reflux and how is it caused?
developmental abnormality of vesicoureteric junction
reflux can cause ureteric dilatation which causes incomplete bladder emptying, renal damage and pyloneprhitis
Causes: family history, after an UTI, bladder pathology
How might an infant with an UTI present?
fever vomiting poor feeding irritable lethargic sepsis !!!!
How might an older child with an UTI present?
dysuria increased frequency of urination abdominal pain/ loin tenderness fever vomiting haematuria cloudy, offensive urine
How is an UTI first diagnosed?
1st line = urine dipstick -> screening test, +ve leucocytes or nitrates
if +ve = clean catch urine sample MC&S
Which investigation should be done routinely in all children with an UTI?
ultrasound within 6 weeks
to identify structural abnormalities, obstruction or scarring
DMSA (for renal scarring) after 3 months if USS atypical or under 3 y/o OR micturating cystourethrogram if <1y/o
Outline the conservative advice given for children with an UTI
high fluid intake regular voiding ensure complete bladder emptying training good perineal hygiene prevent constipation probiotics encouraged
Who should you refer to the hospital with an UTI?
<3 months old
children at high of serious illness
suspect sepsis
Which antibiotic should be prescribed for a child <3 months with an UTI?
IV cefotaxime
Which antibiotic should be prescribed for children >3 months with upper UTI/ pyelonephritis ?
oral co-amoxiclav for 7-10 days
OR
IV cefotaxime for 2-4 days and then oral for up to 7-10 days in total
Which antibiotic should be prescribed for children with a lower UTI or cystitis?
trimethoprim
nitrofurantoin
what are the features of an upper UTI or acute pyelonephritis?
temp >38 degrees
loin pain
loin tenderness
bacteriuria
What are the two types of haematuria?
- glomerular haematuria
2. lower urinary tract haematuria
What is the difference between glomerular and lower urinary tract haematuria?
glomerular haematuria = brown coloured, with proteinuria
lower urinary tract haematuria = bright red colour, no proteinuria
List the non glomerular causes of haematuria
infection e.g. schistomiasis, TB trauma stones sickle cell disease bleeding disorders renal vein thrombosis HSP
list the glomerular causes of haematuria
acute/ chronic glomerulonephritis
familial nephritis
IgA nephropathy
nephritic syndrome
If the urine is red in colour/ +ve haemoglobin on dipsticks, which tests should be done?
urine microscopy and culture
ultrasound
FBC, U&E, clotting screen, creatinine
When is a renal biopsy indicated?
persistent proteinuria
recurrent macroscopic haematuria
renal function abnormal
What are the 2 types of proteinuria?
- transient proteinuria
2. persistent proteinuria
What is the difference between transient and persistent proteinuria?
transient can occur during febrile illness or after exercise
persistent is significant and need to measure urine protein: creatinine in early morning
What are the possible causes of proteinuria?
orthostatic proteinuria nephrotic syndrome increased glomerular filtration pressure hypertension henoch schlonlein purpura UTI chronic renal disease
What is the triad for nephrotic syndrome?
- proteinuria
>1g/m^2/24 hours - hypoalbuminaemia
<25g/L - peripheral oedema
e. g. scrotal, periorbital, ascites, ankle
What is the aetiology of nephrotic syndrome?
Minimal change disease ** (80%)
focal segmental glomerulonephritis
membranous glomerulonephritis
infections
HSP
What can cause minimal change disease?
hodgkins lymphoma
NSAIDs
HIV, hepatitis, syphilis
What are the 3 types of nephrotic syndrome and their differences?
- steroid sensitive nephrotic syndrome **
precipitated by resp infection - steroid resistant nephrotic syndorme
can’t treat with steroids, treat oedema with diuretics, salt restriction - congenital nephrotic syndrome
rare, first 3 months of life, need nephrectomy or dialysis and renal transplant
How is nephrotic syndrome investigated?
urine dipstick
urine microscopy and culture
UandE, FBC, ESR, creatinine, albumin
hepatitis B and C screen
How is nephritic syndrome managed?
high dose of oral corticosteroids (prednisolone)
+ fluid balance, manage electrolytes, penicillin prophylaxis (as lose immunoglobulins so at risk of infection), pneumococcal vaccination
How is steroid resistant nephrotic syndrome managed?
TREAT THE OEDEMA
- diuretics
- salt restriction
- ACE-I
- NSAIDs
What is nephritic syndrome?
inflammation of the kidneys causing…
- haematuria
- hypertension
- proteinuria
+ oliguria, blurred vision, uraemia
What is nephritic syndrome commonly caused by in children?
Alport syndrome
IgA nephropathy “bergers disease”
often following an URTI
post streptococcal glomerulonephritis
Henoch Schonlein Purpura
Haemolytic Uraemic syndrome
What is henoch schonlein purpura?
IgA mediated small vessel vasculitis
What is the triad for henoch schonlein purpura?
- purpura - raised like sandpaper, over buttocks and extensor surfaces
- arthritis - knees and ankles
- abdominal pain
What is henoch schonlein purpura associated with?
IgA nephropathy
following a URTI
What would you expect to see on the urine dipstick of someone with HSP?
proteinuria
haematuria
How is HSP managed?
oral prednisolone
complications: HTN, abnormal kidney function
What is the classical triad for haemolytic uraemic syndrome?
- acute renal failure (decreased urine output, abdo pain)
- thrombocytopenia
- microangiopathic haemolytic anaemia
What are the complications of haemolytic uraemic syndrome?
hypertension
chronic renal failure
What can cause haemolytic uraemic syndrome?
bloody diarrhoea- E.coli *** tumours pregnancy SLE HIV
How is haemolytic uraemic syndrome managed?
supportive
fluids
plasma exchange if severe
How is dehydration managed fluids wise?
10-20ml/kg of 0.9% saline bolus stat
What is the rate of maintenance fluids?
Rate (ml/hour) = total daily requirement / 24
Which fluids are used for maintenance fluids?
0.9% saline + 5% dextrose + 10mmol KCl
How is total daily fluid requirements (24hr) calculated)?
1st 10kg body weight = 100ml/kg/day
2nd 10kg body eight = 50ml/kg/day
remainder body weight= 20ml/kg/day
How is vesico ureteric reflux diagnosed?
** micturating cystourethrogram **
then do DSMA to look for renal scarring
list the signs of shock
decreased LOC cold extremities mottled weak peripheral pulse hypotension prolonged cap refill time
Describe the pathological features of coeliac in the small intestine?
villous atrophy
epithelial cell hyperplasia
mucosal inflammation
increase depth of crypts
what is biliary atresia?
destruction or absence of the extra hepatic biliary tree and intrahepatic biliary ducts leading to chronic liver failure
How does biliary atresia present?
neonatal jaundice faltering growth pale stools dark urine hepatomegaly
How is biliary atresia diagnosed?
laparotomy by operative cholangiography **
ultrasound
conjugated bilirubin high
How is biliary atresia managed?
must be operated on within 60 days of life (surgical bypass of fibrotic ducts / Kasai procedure)
complications of surgery: cholangitis, malabsorption of fats, cirrhosis, liver transplant if unsuccessful
