Ch 13 - Gastroenterology

Question 1

Gastro-oesophageal reflux: RFs (3)

Answer 1

Mainly liquid diet
Mainly Horizontal posture
short intra-abdominal oesophageal length

Question 2

Gastro-oesophageal reflux - features (5)

Answer 2

regurgitation/ vomitting
difficulty feeding
pain during/after feed
aspiration
apnoeic episodes 
putting on weight normally

Question 3

Gastro-oesophageal reflux: Ix (3)

Answer 3

Clinical
24hr oesophageal pH monitoring: pH4 hrs
Endoscopy

Question 4

Gastro-oesophageal reflux: management - conserative (3), medical (3), surgical (1)

Answer 4

Conservative - thickening agents e.g. nestargel/carobel, 30 degrees head up post feed, smaller more freq meals
Medical - Gaviscon, ranitidine, PPIs, domperidone
Surgical - if unresponsive to intensive medical treatment - Nissen’s fundoplication (fundus of stomach wrapped around intra-abdominal oesophagus)

Question 5

Pyloric stenosis: Cause

Answer 5

Pyloric hypertrophy results in gastric outlet obstruction

Question 6

Pyloric stenosis : Features (7)

Answer 6

age group 2-7 weeks
boys 4:1 with maternal FH
Vomiting (not bile stained) - becomes projectile eventually
hunger after vomiting - until dehydration leads to loss of interest
weight loss
hypocholraemic metabolic alkalosis (due to vomiting stomach contents) + hypokalaemia + hyponatremia

Question 7

Pyloric stenosis: Ix (3)

Answer 7

Test feed (using milk) - may see peristalsis in abdomen
Pyloric RUQ mass 
USS - if diagnosis still in doubt

Question 8

Pyloric stenosis Management: (2)

Answer 8

First correct any fluid/electrolyte imbalance

Ramstedt’s pyloromyotomy - divide the hypertrophied muscle down to the mucosa

Question 9

Crying - most imp cause: (1)

Answer 9

Colic: should resolve by 4 months of age; paroxysmal inconsolable crying + drawing up knees + passage of excessive flatus several times/day.

Question 10

Acute appendicitis: features (5)

Answer 10

Colicky pain initally umbilical then localizes to RIF
Fever
anorexia
peritonitis - aggravated by movement
tenderness + guarding in RIF (mcburney’s point)

Question 11

Acute appendicitis: Ix (2)

Answer 11

clinical

USS - may show thickened non-compressible appendix with increased blood flow

Question 12

Acute appendicitis: management (2)

Answer 12

Appendicectomy; if guarding associated with perforation give IV fluids + ABs prior to surgery
If no peritonitis consider conservative management with delayed appendicectomy

Question 13

Non-specific abdo pain + mesenteric adenitis features

Answer 13

NSAP - abdo pain self-resolves in within 48hrs +/- URTI & cervical lymphadenopathy
Mesenteric adenitis: preceding URTI > abdo pain (can only diagnose for sure if find children with large mesenteric LNs on laparscopy + normal appendix)

Question 14

Intussusception: definition + age group

Answer 14

Invagination of proximal bowel into distal segment; commonly ileum into caecum via ileocaecal valve
Age - 3 months to 2 yrs

Question 15

Intussusception: features (6)

Answer 15

Paroxysmal severe colicky pain
Pallor + drawing up of legs during episodes
Vomiting - bile stained
Abdo distension
‘Sausage shaped’ mass
‘Redcurrant jelly’ stool - blood-stained mucus

Question 16

Intussusception: Ix (2)

Answer 16

USS - target like (doughnut) mass

AxR - Distended small bowel + no gas in distal colon/rectum

Question 17

Intussusception: management (2)

Answer 17

IV fluid resusc > rectal air insufflation

surgery

Question 18

Meckel Diverticulum: defintion + features (4)

Answer 18

Ileal remnant of vitello-intestinal duct (present at 2 yrs)
Features: severe rectal bleeding
Intussusception
Volvulus around a band
Diverticulitis which mimics appendicitis

Question 19

Meckel diverticulum: Ix (1) & management (1)

Answer 19

Tecchnetium scan showing increased uptake by ectopic gastric mucosa
Surgical resection

Question 20

Malrotation: definition

Answer 20

During foetal life if mesentery is not fixed, there can be incorrect positioning of intestingal components.
Ladd bands may obstruct duodenum ( so most common form of malrotation is where caecum stays high and fixed to the posterior abdo wall - it is fixed by these Ladd bands)
Volvulus may occur
Children present at 1-3 days of life (although can present later with bilous vomiting)

Question 21

Malrotation: features (2 presentations)

Answer 21

Either features of obstruction alone - usually present with bilious vomiting
Or obstruction + compromised blood supply

Question 22

Malrotation: Ix & management

Answer 22

Upper GI contrast study

Surgery - the malrotation isnt corrected as such, instead the mesentery is broadened + appendix removed

Question 23

What is defined as recurrent abdo pain? (3)

Answer 23

Abdo pain affecting lifestyle > 3 months

A cause is identified in

Question 24

Features of abdo migraine (4)

Answer 24

Abdo pain (midline)
headache
pallor + vomiting
FH of migraines

Question 25

IBS: definition + features (4)

Answer 25

Diagnosis of exclusion! altered gut motility + altered perception of intra-abdo events Features: abdo pain relieved by defacation, explosive stools, mucusy stools, cycles of constipation/diarrhoea, bloating, tenesmus

Question 26

Peptic ulceration, gastritis & functional dyspepsia: cause (1), features (2), diagnosis (3)

Answer 26

H. pylori Epigastric pain, relieved with food/milk C13 breath test, stool test, urease detection

Question 27

Peptic ulceration, gastritis & functional dyspepsia: Management (3)

Answer 27

Triple therapy: omeprazole +/- amoxicillin + clarithromycin/metronidazole

Question 28

Functional dyspepsia - 3 features

Answer 28

Early satiety post prandial vomiting Delayed gastric emptying

Question 29

Causes of gastroenteritis (6)

Answer 29

Rotavirus (developed countries) Norovirus, adenovirus, coronavirus Campylobacter (crampy abdo pain + bloody stool) Shigella & salmonella (blood + pus in stool + pain) Cholera

Question 30

Dehydration: assessment (10)

Answer 30

``` Consciousness Fontanelle - sunken? sunken eyes Pale/mottled skin reduced cap refill Tachycardia Tachypnoea Oliguria sudden weight loss dry mucous membranes ```

Question 31

Dehydration: grading (3)

Answer 31

None/ 10% of BW

Question 32

Dehydration: Iso/hyponatremic vs hypernatremic dehydration

Answer 32

Iso/hypo - in developing countries due to malnourishment Hypernatremic - fever/hot environment/ profuse low sodium diarrhoea: jittery movement, hyperreflexia, multiple small cerebral haemorrhages

Question 33

Dehydration: complication of hyponatremic cases

Answer 33

this happens when children with diarrhoea drink lots of iso/hypotonic solution > means net loss of Na > H2O...so end up with hyponatremia. This means H2O moves from EC (plasma) into IC (cells) > brain swelling > convulsions.

Question 34

Dehydration: physiology of hypernatremic cases

Answer 34

in some cases the loss of H20 exceeds loss of Na e.g. low Na diarrhoea. Here the hypernatremia leads to drawing in of H2O from IC to EC...which means the clinical signs of dehydration are far less pronounced e.g. sunken fontanelle, sking rugor etc. Making it MUCH HARDER to detect clinically. Loss of water from brain cells causes atrophy - leads to jittery movements, altered consciousness etc.

Question 35

Dehydration: management (3)

Answer 35

Clincal dehydration - ORS (oral rehydration solution) if hypernatremic dehydration - (need to be careful as giving fluid will rapidly reduce osmolality and H2O will enter brain cells > cerbral oedema) should be done over 48hrs with correction in OSMOLALITY at

Question 36

Post-gastroenteritis syndrome: what is it? diagnosis? managment (2)

Answer 36

Return of watery diarrhoea following introduction of normal diet (after having had gastroenteritis) Happens in some cases, temporary lactose intolerance may have developed > which can be diagnosed by seing unasborbed sugars in stool POSITIVE CLINITEST Manage with ORS & continued introduction of normal diet

Question 37

Coeliac disease: definition

Answer 37

Malabsorptive disease due to gluten intolerance - specifically gliadin

Question 38

Coeliac disease: features (5)

Answer 38

``` Failure to thrive abdo distension foul-smelling stools wasting of buttocks anaemia ```

Question 39

Coeliac disease: Diagnosis (2)

Answer 39

Endoscopy - jejunal biopsy: subtotal villous atrophy + crypt hyperplasia Anti-tTGA abs + anti endomysial + anti gliadin abs

Question 40

Coeliac disease: management (1)

Answer 40

gluten-free diet

Question 41

Toddler diarrhoea: defintion

Answer 41

Commonest cause of perisistent lose stools in preschool children; most grow out of symptoms by 5 yrs

Question 42

Toddler diarrhoea: feaures (3)

Answer 42

Stools of varying consistency, well formed to explosive undigested veggies in stools children well + thriving

Question 43

Toddler diarrhoea: management (2)

Answer 43

Adequate fat in diet - to slow transit | low fruit juice - esp those high in non-absorbaly sorbitol

Question 44

Crohn's Disease: Definition, Features (6)

Answer 44

Inflammatory disease of GIT from mouth to anus; most commonly distal ileum + prox colon Features: oral lesions, perianal skin tags, arthralgia, fistulae, (abdo pain + diarrhoea), growth failure/ delayed growth, cobblestone mucosa, weight loss

Question 45

Crohn's Disease: Diagnosis (2 )

Answer 45

endoscopy - non-caseating epitheloid granulomata | Faecal calprotectin

Question 46

Crohn's Disease: Management (4)

Answer 46

Remission induction: nutritional therapy - whole protein modular feeds for 8 weeks, steroids if nutrition therapy ineffective Remission maintenance: azathioprine, methotrexate, mercaptopurine; infliximab Surgical - obstruction, fistulae, abscesses

Question 47

Ulcerative colitis - definition, features (6)

Answer 47

Inflammatory bowel condition affecting only COLON; beigns at anus and moves proximally Features - colicky abdo pain, bloody stools, erythema nodosum, weight loss, arthritis, erythema nodosum

Question 48

Ulcerative colitis: diagnosis (2)

Answer 48

Endoscopy - confluent colitis from recctum proximally | Histology - mucosal inflammation, cryp damage and ulceration

Question 49

Ulcerative colitis: management (4)

Answer 49

Mild - aminosalicylates e.g. mesalazine Severe - systemic steroids(acute), azatioprine (maintain remission) Confined to rectosigmoid - topical steroids Surgical - colectomy + ileostomy/ileorectal puch (if severe disease)

Question 50

Normal bowel movements in following ages: Week 1, year 1, breast fed

Answer 50

Week-1: 4/day 1 year: 2/day breast fed: may not pass stools for days and still be healthy

Question 51

Red flags of constipation: what do they indicate? No meconium within first 48hrs of life Failure to thrive Gross abdo distension abnormal lower limb neurology/ deformity Sacral dimple above natal cleft, over spine; naevus Abnormal anal appearance/ position/ patency Perianal bruising/ multiple fissures Perianal fistulae

Answer 51

``` 1 - Hirschsprung disease 2 - Coeliac, hypothyroid 3 - Hirschsprung disease/ other GI dismotility 4 - lumbosacral path 5 - spina bifida occulta 6 - anatomical abnormality 7 - sexual abuse 8 - Crohn's disease ```

Question 52

Hirschsprung disease: definition

Answer 52

Absence of myenteric nerve plexuses > narrow contracted bowel segment

Question 53

Hirschsprung disease: features in neonates (4)

Answer 53

NO MECONIUM in first 24hrs Billous vomiting abdo release of flatus/ liquid stool when finger withdrawn from DRE

Question 54

Hirschsprung disease - features in late childhood (2)

Answer 54

``` Chronic constipation (but no soiling) Growth failure ```