Paeds Written - Gastro Flashcards
Features of severe cow’s milk allergy
Failure to thrive
Severe atopic dermatitis
Laryngo-oedema / angioedema
Anaphylaxis
Management of cow’s milk allergy
Severe Sx –> refer to Paeds
FORMULA FED
- swap to extensively hydrolysed formula
- if no response –> amino acid formula
BREASTFED
- continue breastfeeding
- eliminate cow’s milk from maternal diet
- +/- calcium supplements for mum
- THEN extensively hydrolysed formula when breastfeeding stops until 12 months old / for at least 6 months
Prognosis of cow’s milk allergy
IgE mediated - 55% are tolerant at 5yo
Non IgE mediated - most children tolerant by 3yo
Risk factors for GORD
Pre-term delivery
Neurological disorders
1st line for GORD
1-2 week trial Alginate suspension (Gaviscon)
- should NOT be used at same time as thickeners
2nd line for GORD
4 week trial of PPI (omeprazole)
Alternative/Later Tx for GORD
Metoclopramide - only with specialist advice
Fundoplication - if severe complications + medical Tx ineffective
Conservative advice for babies with reflux/regurgitating feeds
Position during feeds - 30 degrees, head up
Sleep on back as per standard SIDS guidance
Ensure not being overfed
Consider trial of smaller + more frequent feeds
Trial of thickener e.g. rice starch, cornstarch
Distinguishing mesenteric adenitis from appendicitis?
Both - central or RIF pain
Mesenteric:
- no anorexia
- lack of rebound tenderness
- shifting tenderness (if child turns to left side)
- preceded by URTI or gastroenteritis
Appendicits
- high grade fever
Definitive Dx for mesenteric adenitis
Large mesenteric lymph nodes seen at laparoscopy (with normal appendix)
Tx for mesenteric adenitis
Analgesia
Antipyretics
Delivery requirements if exomphalos found on USS
C section
to reduce risk of sac rupture
Clinical features of Exomphalos
Abdominal contents protrude from anterior abdominal wall
Covered by amniotic sac (formed from amniotic membrane + peritoneum)
Associations with Exomphalos
Beckwith Wiedemann syndrome
Down syndrome
Cardiac & kidney malformations
Principles of surgery for exomphalos
Staged closure preferred to primary closure (Esp for large defect)
Sac granulates + epithelialises over weeks - months
Once infant has grown (enough for sac contents to fit inside abdomen) - shell removed + abdomen closed
Completed by 6-12 months
Clinical features of Gastroschisis
Abdominal contents outside of body (via anterior paraumbilical abdominal wall)
without peritoneal covering
Delivery requirements for Gastroschisis
If found on antenatal USS can still attempt vaginal delivery
BUT
Cling film to protect bowel + go to theatre ASAP after delivery (within 4 hours)
Examination findings in Pyloric stenosis
Olive shaped mass in RUQ/epigastric region
Succussion splash on auscultation of stomach
Visible peristalsis
Typical age for pyloric stenosis
4-6 weeks old
Range 1-10 weeks
Diagnostic Ix for pyloric stenosis
Abdo USS or Test feed
VBG findings in pyloric stenosis
Hypochloraemic
Hypokalaemic
Metabolic alkalosis (High bicarb)
Definitive Tx for pyloric stenosis
Ramstedt pyloromyotomy
- Does NOT open GI tract (i.e. enter lumen)
- Vertical cut across pylorus –> increases lumen diameter
- Open or laparoscopic
Management of appendicitis
GAME
- Group & Save
- Abx IV
- MRSA screen
- Eat & drink - NO, NBM
+ Appendicectomy
Epidemiology of appendicitis in children
most common cause of abdo pain in child
BUT rare before 3yo
Pathophysiology of Mecekls’s diverticulum
Continued latency of vitelline duct (omphalomesenteric duct / vitelliointestinal duct)
Normally disappears at 6 weeks gestation
Results in ectopic site of gastric, pancreatic or ileal epithelial tissue
Rule of 2s (Meckel’s)
2 feet from ileocaecal valve
2 inches long
Affect 2% population
(Male: female = 2:1)
Most common cause of painless rectal bleeding in children?
Meckel’s diverticulum
Diagnostix Ix for Meckel’s diverticulum
Technetium-99m scintigraphy / pertechenate study of GI tract - shows ectopic uptake by gastric mucosa
Mesenteric arteriography (if severe i.e. needing transfusion)
Surgical management of Meckel’s diverticulum
Wedge excision OR
Formal small bowel resection + anastomosis
key clinical feature of malrotation / volvulus
Bile stained vomiting
Ix required in suspected malrotation/volvulus
upper GI contrast study - urgent
- assess patency
- done if bilious vomiting
USS
Pathophysiology of Hirschprung’s disease
Absence of ganglion cells from Auerbach (myenteric) and Meissner (submucosal) plexuses
In distal colon & rectum
Causing uncoordinated peristalsis + functional obstruction
Gold standard IX for Hirschprung’s disease
(Suction assisted) Full thickness rectal biopsy
Complications of Hirschprung’s disease
Meconium plug syndrome
Hhrsicprung’s enterocolitis - life threatening C. diff, perforation
Treatment options for Hirschprung’s
Rectal washout/bowel irrigation
Surgery - anorectal/endorectal pull through
Conditions associated with meconium ileus
Cystic fibrosis
Biliary atresia
Management of meconium ileus
PR contrast studies e.g. Gastrograffin enema, N-acetylcysteine
- diagnostic + potentially therapeutic (1st line)
2nd line if no response = surgical decompression
Causes of Intussusception
Idiopathic
Enlarged Peyer’s patch - acts as lead point, after gastroenteritis
Hypertrophy in CF
Symptoms & signs of Intussusception
Intermittent colicky pain - may draw legs up
Diarrhoea
Vomiting - may be bile stained
Red current jelly stool = late sign, emergency!
Abdo distension
Sausage shaped mass in RUQ
Dance’s sign - emptiness on palpation of RLQ
1st line imaging in suspected Intussusception
Abdo USS –> target sign
Management options in Intussusception
1st line = air insufflation (or contrast enema)
2nd line (or if perforation) = surgical reduction
+ Broad spectrum Abx e.g. clindamycin + gentamicin
What should be done in recurrent intussusception?
Investigate for pathological lead point
- Meckel diverticulum
- Polyp
Red flag features in constipation
Failure to pass meconium in first 24h = Hirschsprung’s
Faltering/failure of growth = Hypothyroid, Coeliac
Gross abdo distension = Hirschsprung’s
Abnormal LL neurology or deformity = lumbosacral pathology
Cutaneous marker above natal cleft/on spine = Spina bifida occulta
Abnormal appearance/position/patency of anus = anorectal malformation
Perianal bruising or fissures = sexual abuse
Perianal fistulae, abscesses or fissures = Crohn’s
Behavioural interventions for constipation
Scheduled toileting - after meals to utilise gastrocolic reflex
Bowel habit diary
Reward system
Daily physical activity
Diet & fluid intake - fruit & veg, high fibre bread
Medical management of disimpaction
1st line = Mocivol paediatric plain (Polyethylene glycol 3350 + electrolytes)
- escalating dose regimen
- e.g. 4 sachets on day 1 –> increase by 2 sachets each day to max 12
- review within 1 week
2nd line = add stimulant (e.g. Senna)
- if not disimpacted within 2 weeks
If not tolerating Movicol, switch to stimulant +/- osmotic (lactulose)
Medical maintenance for constipation
Polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain)
- aim for 1 soft stool per day
- can be used long term - no danger!
- THEN gradually reduce over months
Associations with umbilical hernia
Afro-Caribbean
Down’s syndrome
Mucopolysaccharide storage disease
Elective repair of umbilical hernia - indications & timeline
Large (>1.5cm) or symptomatic = elective repair at 2-3 years
Small and asymptomatic = elective repair at 4-5 years
Acute emergencies of umbilical hernias
Incarceration during observation period
- needs manual reduction
- THEN surgery within 24 hours
Irreducible –> emergency surgery
Risk factors for indirect inguinal hernia
Male
Premature
Connective tissue disorders
Management of indirect inguinal hernia
High risk of strangulation / incarceration –> urgent surgery
- <6w old = within 2 days
- <6m old = within 2 weeks
- <6yo old = within 2 months
Signs of incarcerated hernia
Tender, firm mass Poor feeding Bowel obstruction - no stool Vomiting Overlying skin changes
Management options for anal fissure
Increase dietary fibre
Increase fluid intake
Advise against stool withholding
Pain management
- simple analgesia
- sit in shallow warm bath
- topical anaesthetic e.g. lidocaine, GTN ointment
Consider constipation Tx pathway
Pathophysiology of anal fissure
Tears in skin around anus
Usually due to constipation: sphincter stretched to allow hard, dry stool to pass
Dietary interventions for toddler’s diarrhoea
Reduce refined sugar
Avoid excessive fluid + fibre intake
Most commonly affected sites in Crohn’s disease
Distal ileum
Proximal colon
Biopsy finding in Crohn’s
non-caseating epithelioid cell granulomata
Important Ix in Crohn’s
FBC - iron, B12, folate
CRP, ESR
Faecal calprotectin
Colonscopy + biopsy
Consider anxiety + depression scoring systems to assess impact on life
Tx to induce remission in Crohn’s
Nutritional = Whole protein modular diet
- 6-8 weeks
- mostly liquid
- may need NG tube
- easily digested products –> put on lost weight
Pharmacological = Steroids (prednisolone)
Maintaining remission in Crohn’s disease
Aminosalicylates (e.g. mesalazine)
Immunosuppressive drugs (azathioprine, methotrexate, mercaptopurine)
Anti-TNF antibodies (e.g. infliximab)
Why should azathioprine NOT be given to?
People with TPMT mutation
- can’t metabolise drug –> BM toxicity?
Role of surgery in Crohn’s?
Is NOT curative - can affect anywhere from mouth –> anus
But used for complications:
- obstruction
- fistula
- abscess
- severe localised disease unresponsive to medical Tx
Colonoscopy & Histology features in Ulcerative colitis
Confluent colitis - extends from rectum proximally
Mucosal inflammation / ulceration
Crypt damage - abscess, loss, architectural distortion
Severity grading system in UC?
Paediatric ulcerative colitis activity index (PUCAI)
- severe = >65 points
- mild-moderate = 10-64 points
Truelove & Witts score
Important complications/associations of UC
Enteric arthritis
Toxic megacolon
Perforation
Bowel & liver cancer
Primary sclerosis cirrhosis
Management of Severe fulminating UC
MDT - medics, surgeons
IV corticosteroids or ciclosporin
Assess need for surgery. More likely if:
- stool frequency >8/day
- tachycardia
- pyrexia
- low Albumin, low Hb, high platelets or CRP
- AXR showing colonic dilatation
Management of UC
1st line = aminosalicylates
- topical –> oral if no improvement after 4 weeks
2nd line = topical –> oral corticosteroid
3rd line = oral tacrolimus
4th line = biologics e.g. infliximab
5th line - surgery
Coeliac disease HLA associations
HLA-DQ2
HLA-DQ8
Key clinical features of coeliac disease
Bloating, irritability, diarrhoea
Malnutrition
- buttock wasting
- distended abdomen
Dermatitis herpetiformis = pruritic, papulovesicular elbow or knee rash
Antibody tests for coeliac disease
IgA tissue transglutaminase (anti TTH) - most sensitive
IgA anti-endomysial cell antibodies - less sensitive
NOTE: send IgA at same time - deficiency can cause false negative
What Ab can be used to diagnose coeliac disease if IgA deficient ?
IgG deiminated gliadin peptide (DGP)
Confirmatory Ix for coeliac disease
Older children –> OGD + jejunal biopsy
Young children –> only Ab & HLA testing
Biopsy findings in coeliac disease
Crypt hyperplasia
Villous atrophy
intraepithelial lymphocytes (IELs)
Principles of coeliac disease management
MDT!
Strict gluten free diet
+ Refer to dietician for support
Annual 6m-12m review:
- height & weight
- symptoms
- adherence to diet
- blood tests?
Complications of coeliac disease (poorly treated or untreated)?
Enteropathy associated T cell lymphoma (EATL)
Micronutrient deficiencies
Hyposplenism
Diagnostic biochemical abnormality in rickets
Ca^2+ x PO4^2- = <2.4
both calcium + phosphate low
