Upper and lower GI Flashcards
What are the different types of vomiting?
Vomiting with retching
Projectile vomiting
Bilious vomiting
Effortless vomiting
What are the three phases of vomiting with retching?
Pre-ejection phase
Ejection phase
Post-ejection phase
What are the signs of the pre-ejection phase of vomiting with retching?
Pallor
Nausea
Tachycardia
What are the parts of the ejection phase of vomiting with retching?
Retch
Vomit
What can stimulate the vomiting centre of the brain?
Enteric pathogens Intestinal inflammation Metabolic derangement Infection Head injury Visual stimuli Middle ear stimuli
CS: 6wk boy, 3wk Hx vomiting after every feed, bottle fed 6oz 3hrly, vomitus: large volume, milky/curdy, mostly projectile Irritable/crying Not gaining weight adequately O/E: slightly dehydrated
What are the differential diagnoses?
Gastro-oesophageal reflux
Overfeeding
Pyloric stenosis
What is an olive tumour?
Olive-shaped mass in abdomen in upper left quadrant of epigastric region
What is a visible sign of pyloric stenosis?
Visible gastric peristalsis
What is an olive tumour indicative of?
Pyloric stenosis
What is the vomiting like with pyloric stenosis?
Projectile non bilious vomiting
What is the management of pyloric stenosis?
Fluid resuscitation (for dehydration) Refer to surgeons
What is the surgery for pyloric stenosis?
Ramstedts pyloromyotomy
What age does pyloric stenosis usually present?
4-12 weeks
Does pyloric stenosis usually present in boys or girls more?
Boys
What is the characteristic electrolyte disturbance of pyloric stenosis?
Metabolic alkalosis (↑ pH)
Hypochloraemia (↓Cl)
Hypokalaemia (↓K)
What are the signs of physical signs pyloric stenosis?
Projectile non-bilious vomiting
Weight loss
Dehydration +/- shock
What is bilious vomiting usually due to unless proven otherwise?
Intestinal obstruction
What are the main causes of bilious vomiting?
Intestinal atresia Malrotation +/- volvulus Intussusuception Ileus Crohn's disease with strictures
What is a volvulus?
When a loop of intestine twists around itself and the mesentery that supports it, resulting in a bowel obstruction
What is ileus?
Lack of movement somewhere in the intestines that leads to a buildup and potential blockage of food material
What is intussusception?
One segment of intestine “telescopes” inside of another, causing an intestinal obstruction (blockage)
What are the investigations for bilious vomiting?
Abdominal XR Contrast meal Surgical opinion (exploratory laparotomy)
What is effortless vomiting usually due to?
Gastro-oesophageal reflux
What are the cases when gastro-oesophageal reflux may not spontaneously resolve?
Cerebral palsy
Progressive neuro problems
Oesophageal atresia +/- TOF operated
Generalised GI motility problem
What are the presenting symptoms of reflux?
Vomiting Haematemesis Feeding problems Failure to thrive Apnoea Cough Wheeze Chest infections Sandifer's syndrome
What is Sandifer’s syndrome?
Neurological: involves spasmodic torsional dystonia with arching of the back and rigid opisthotonic posturing, mainly involving the neck, back, and upper extremities, associated with symptomatic gastroesophageal reflux, esophagitis, or the presence of hiatal hernia
What is the medical assessment for reflex?
History and exam Video fluroscopy Barium swallow pH study Oesophageal impedance monitoring Upper GI endoscopy
What problems can be identified on barium swallow?
Dysmotility Hiatus hernia Reflux Gastric emptying Strictures
What are the problems with barium swallow?
Aspiration
Inadequate contrast taken
What are the positive points of videofluroscopy and barium meal?
May detect aspiration
Defines anatomy well
What are the negative points of videofluroscopy and barium meal?
May miss reflux
Radiation
What are the positive points of pH study?
Detects acid reflux missed by barium
What are the negative points of pH study?
Only detects acid reflux
May be unpleasant for child
What are the positive points of endoscopy?
Best test for oesophagitis
Can be combined with pH+ impedance study
What are the negative points of endoscopy?
Needs anaesthetic
What are the positive points of trial feeding?
Most physiological test
May be best discriminator if child needs surgery
What are the negative points of trial feeding?
NG tube required
Needs 2-3 days in hospital
What is the treatment for gastro-oesophageal reflux?
Feeding advice
Nutritional support
Medical treatment
Surgery
What is the feeding advice for gastro-oesophageal reflux?
Thickeners for liquids
Appropriateness of foods: texture/amount
Behavioural programme: oral stimulation/removal of aversive stimuli
Feeding position
What nutritional support can be given to babies with gastro-oesophageal reflux?
Calorie supplements
Exclusion diet (milk free)
NG tube
Gastrostomy
What medical treatment can be given for gastro-oesophageal reflux?
Feed thickener: Gaviscon
Prokinetic drugs
Acid suppressing drugs: H2 receptors blockers/PPI
What are the indications for surgery in gastro-oesophageal reflux?
Failure of medical treatment
Persistent: failure to thrive, aspiration, oesophagitis
What is Nissan fundoplication?
A surgical procedure that corrects GERD by creating an improved valve mechanism at the bottom of the oesophagus - it is meant to prevent the flow of acids upward
For which group of patients might surgery be more complication for those with GOR?
Cerebral palsy
What is the definition of chronic diarrhoea?
4 or more stools a day
>4 weeks
What is the definition of acute diarrhoea?
4 or more stools a day
<1 week
What is the definition of persistent diarrhoea?
4 or more stools a day
2-4 weeks
What are the three main groups of causes of diarrhoea?
Motility disturbance
Active secretion (secretory)
Malabsorption of nutrients (osmotic)
What conditions come under osmotic diarrhoea?
Food allergy
Coeliac disease
CF
What is the management of osmotic diarrhoea?
Removal of causative agent
What conditions come under secretory diarrhoea?
Acute infective diarrhoea
IBD
What is secretory diarrhoea associated with?
Toxin production
What conditions can cause motility diarrhoea?
Toddler’s diarrhoea
IBS
Congenital hyperthyroidism
Chronic intestinal pseudo-obstruction
What is inflammatory diarrhoea?
Malabsorption due to intestinal damage
Accelerated transit time in response to inflammation
Which type of diarrhoea has a larger volume: osmotic or secretory?
Secretory
Which type of diarrhoea stops in response to fasting?
Osmotic
Which diseases cause fat malabsorption and diarrhoea?
Pancreatic disease (CF) Hepatobiliary disease
What are the signs and symptoms of coeliac disease?
Abdominal bloatedness Diarrhoea Failure to thrive Short stature Constipation Tiredness Dermatitis herpatiformis
What are the screening tests for coeliac disease?
Serological screens
Duodenal biopsy
Genetic testing
What are the serological screens for coeliac disease?
Anti-tissue transglutaminase
Anti-endomysial
Anti-gliadin
IgA dependent test
How would you diagnose children with coeliac disease with the ESPGHAN guidelines?
Symptomatic
Anti TTG >10 times upper limit of normal
Positive anti-endomysial antibodies
HLA DQ2, DQ8 positive
What is the treatment for coeliac disease?
Gluten-free diet for life
What questions should you ask about constipation?
How often?
How hard?
Is it painful?
Has there been a change?
What type on the Bristol stool chart are constipated?
Type 1 & 2
What are other signs/symptoms of constipation?
Poor appetite Irritable Lack of energy Abdominal pain/distention Withholding or straining Diarrhoea
Why do children become constipated?
Social: - Poor diet, too many fluids/milk - Potty training/school toilet Physical - Intercurrent illness - Medication FH Psychological Organic
What diet measures can treat constipation?
Increase fibre, fruit, vegetables, fluids
Decrease milk
What psychological factors can treat constipation?
Reduce aversive factors - height, cold, school
Reward good behaviour
What are the different types of laxative that soften stool and stimulate defecation?
Osmotic laxatives - lactulose
Stimulant laxatives - senna, picolax
Isotonic laxatives - movicol
What is the treatment of impaction?
Empty impacted rectum/colon
Maintain regular stool passage
Slow weaning off treatment
What are more common presenting symptoms in UC than Crohn’s?
Diarrhoea and rectal bleeding
What are symptoms of Crohn’s and UC?
Diarrhoea Rectal bleeding Abdo pain Fever Weight loss Growth failure Arthritis
What are more common presenting symptoms in Crohn’s than UC?
Weight loss
Growth failure
What are the investigations for IBD?
FBC & ESR
Stool calprotectin
CRP
What are you looking for the in FBC of someone with IBD?
Anaemia Thrombocytosis Raised ESR Raised CRP Low albumin Raised calprotectin
What are imaging investigations for IBD?
MRI
Barium meal
Endoscopy
What are the aims of treatment in IBD?
Induce and maintain remission
Correct nutritional deficiencies
Maintain normal growth and development
What the methods of treatment for IBD?
Medical: - anti-inflammatory - immuno-suppressive - biologicals Nutritional: - immune modulation - nutritional supplementation Surgical
