Elimination problem Flashcards

Question

How is biliary atresia managed?

Answer 1

Hepato-portoenterostomy is performed Aim is to enable bile to flow into small intestine Not curative - many children need liver transplant

Answer 2

1. Intestinal causes: reflux, pyloric stenosis, malrotation and obstruction, cow's milk protein allergy 2. Infection: UTIs can cause persistent vomiting in children 3. Cerebral disorders: raised ICP 4. Renal: failure, tubular acidosis 5. Metabolic disorders: adrenal failure

Answer 3

Blockage: Malrotation Intestinal atresia (commonly duodenal) Meconium ileus

Answer 4

Bilious or non bilious

Answer 5

Projectile or not?

Answer 6

Pyloric stenosis

Answer 7

**Infection** If they also have diarrhoea: probably gastroenteritis If they do not have diarrhoea: possibly sepsis or meningitis

Answer 8

No signs of raised ICP: reflux Signs of raised ICP: space occupying lesion or hydrocephalus

Answer 9

Non-forceful regurg of contents up the oesophagus, sometimes into mouth **- Babies have weak LO sphincters, have a liquid diet and are often supine = recipe for reflux** Physiological in infants but can be troublesome and cause FTT More common in premature babies and those with neuro-developmental impairment, less common in older children and teenagers

Answer 10

Asymptomatic in most Discomft: draing up legs during or after feeds, arched back, crying Large vomits after feeding FTT if severe Common source of anxiety in parents

Answer 11

Reassurance is often all that is needed Investigate if patient is not growing Overfeeding is a common problem so ascertain how much child is having If patient has neuro-developmental impairment they are at risk of aspiration so surgery may be needed 90% cases resolve by 1 year * Advise regarding position during feeds - 30 degree head-up * infants should sleep on their backs as per standard guidance to reduce the risk of cot death * ensure infant is not being overfed (as per their weight) and consider a trial of smaller and more frequent feeds * a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum) * a trial of alginate therapy e.g. Gaviscon. Alginates should not be used at the same time as thickening agents * * NICE do not recommend a proton pump inhibitor (PPI) to treat overt regurgitation in infants and children occurring as an isolated symptom. A trial of one of these agents should be considered if 1 or more of the following apply: * Unexplained feeding difficulties (for example, refusing feeds, gagging or choking) * distressed behaviour * faltering growth * Ranitidine was previously used as an alternative to a PPI but was withdrawn from the market in 2020 as small amounts of the carcinogen N-nitrosodimethylamine (NDMA) were discovered in products from a number of manufacturers. * prokinetic agents e.g. metoclopramide should only be used with specialist advic *

Answer 12

More common with bottle fed babies as its more difficult for baby to control milk flow Causes wind, cramps, watery poo, foul smelling poo, sleep problems and irritability

Answer 13

Male babies typically (4:1 M:F), hypertrophy of pyloric muscle 2-4/1000 live births **Typical presentation:** 3-8 week old with projectile vomiting **Examination:** hungry, dehydrated, poor weight gain, ripples across abdomen **Diagnosis:** test feed causes projectile vomiting and peristalsis visible on abdomen, small lump palpable, bloods show hypochloraemic, hypokalaemic alkalosis due to vomiting, USS confirms diagnosis - shows thickened pylorus **Management:** correct electrolytes, surgery - Ramstedt's pyloromyotomy (pylorus is cut to widen abnormality) **Good prognosis**, can reintroduce milk almost immediately

Answer 14

Appendicitis, intusussception, Meckel's diverticulum, Mesenteric adenitis, constipation

Answer 15

Severe pain Pain lasting a long time Recurrent pain

Answer 16

**Surgical causes:** appendicitis, intussusception, hernia, testicular torsion **Infective:** gastroenteritis, lower lobe pneumonia, UTI, mesenteric adenitis **Non-infective:** constipation, coeliac disease, IBD, DKA, peptic ulcer, functional/ 'non-organic'

Answer 17

Lumen of appendix occluded by faecoliths Affects any age, 10% of all people during lifetime but most common during teens **Presentation:** decreased appetite, central abdo pain which migrates to RIF, vomiting, fever (LESS SPECIFIC SYMPTOMS IN YOUNGER CHILDREN) **Examination:** guarding and tenderness over RIF, rebound tenderness, rigidity associated with peritonitis if appendix has perforated **Diagnosis:** waised WCC and CRP, USS showing inflamed appendix **Management:** appendicectomy

Answer 18

Invagination of bowel like a telescope, most commonly at terminal ileum which invaginates into caecum & takes mesentery with it Pathophysiology: causes oedema, ischaemia and necrosis + perforation **Presentation:** intermittent pain, drawing up legs, inconsolable crying, vomiting and pallor, palpable sausage-shaped mass, redcurrant jelly blood = late sign ⚠️ **Investigations:** USS shows target sign **Management:** reduce by air enema (works in 70%), 30% need surgery Air can cause or reveal perforation: surgery required Recurs in 5% If symptoms present for 24hrs+ or if suspicion of perforation surgery is needed due to high risk of necrosis

Answer 19

Remnant of vitello-intestinal duct which connects yolk sac and gut during embryonic development Affects 2% population - only 5% symptomatic as bleeding occurs within diverticulum **Presentation:** fresh bleeding from rectum, melaena, low Hb, microcytic anaemia due to chronic bleeding, abdo pain, tenderness near umbilicus **Rule of 2s** - M:F 2:1 - 2yrs old = most common age - 2 feet from ileocaecal valve - 2 inches long - 2 cm wide Diagnosis: USS or AXR may show blockage, radioisotope scan (Meckel's scan) comfirms, faecal sample showing presence of blood, laparotomy Management: surgery

Answer 20

Inflammation of the mesenteric LNs - common cause of abdo pain in children Nodes enlerge due to infection (usually viral e.g. URTI) Self-limiting, give pain relief Pain can mimic appendicitis

Answer 21

Functional abdo pain Poorly localised/ central abdo pain but all investgations are normal Normal growth Management: coping strategies

Answer 22

Poorly localised abdo pain, may be associated with vomiting, family hx of migraines Pain usually resolves as child gets older but many develop migraines later on

Answer 23

Affects up to 30% of children Often due to lack of fibre **Presentation:** abdo pain, poor appetite, infrequent bowel opening, straining, hard & small stool \>\> Pain can lead to child not wanting to use toilet \>\> makes situation worse Soiling is common as liquid overflow bypasses blockage **Diagnosis:** clinical, important to rule out FTT and underlying disease Examination: mass in abdomen commonly LIF, inspect anal area for fissures, don't do PR if suspecting constipation, neuro examination of legs to rule out spinal pathology **Management:** advice re diet and fluid intake, laxatives/ laxitive disimpaction regimen before staring maintenance therapy

Answer 24

Present since birth: may suggest congenital anomaly Delayed passage of meconium: Hirschsprung's or CF FTT: coeliac disease, hypothyroidism, CF Abnormal spine or weakness in legs: spinal abnormality e.g. spina bifida

Answer 25

Lack of energy, feeling the cold, unusual weight gain

Answer 26

Stimulant: senna + sodium picosulphate Osmotic: lactulose Macrogols: bulk the stool e.g. polyethylene glycol and electrolytes

Answer 27

Varies greatly but 3x day in \<6 months then 1x day in those 3yrs+

Answer 28

**If faecal impaction present:** polyethylene glycol + movicol paediatric plan - add stimulant laxative if not cleared after 2 weeks This can initially worsen symptoms and soiling Maintenance therapy: movicol paediatric plan, add stimulant laxative if no response, continue for several weeks after regular habit established then gradually reduce dose Do not use dietary advice as 1st line but do offer advice Consider behavioural interventions to encourage use of toilet Consider asking health visitor to visit to support parents

Answer 29

Bottle fed: give water between feeds, massage belly and bicycle legs Breast fed: v. unusual to be constipated so seek underlying cause

Answer 30

Offer extra water and diluted fruit juice Consider adding lactulose

Answer 31

Infection - gastroenteritis

Answer 32

Diarrhoea could occur following a period of constipation

Answer 33

Hyperthyroidism

Answer 34

CF \>\> pancreatic insufficiency

Answer 35

Very common and affects almost all children at some stage Mainly due to rotavirus - cases have dropped by 70% due to vaccine introduced in 2013 Viral causes much more common than bacterial Highly contagious Peak incidence 9-24 months Course: diarrhoea and vomiting that usually settles after 24hrs, some become severely dehydrated and may need NG oral rehydration or IV fluids if unable to keep oral rehydration solution down

Answer 36

AKA peas and carrots condition Child is thriving and has no abnormal clinical findings but has diarrhoea with presence of undigested food Cause unknown, resolves without intervention but reduced intake of fructose in the form of fruit juice may help symptoms

Answer 37

1/100, occurs when weaning or after (when gluten introduced) Clinical features: bloating, poor weight gain, diarrhoea/ constipation, wasting of gluteal muscles, iron deficiency anaemia **Diagnosis:** Anti-TTG antibodies high (may be falsely low if patient deficient in IgA or they havent eaten gluten recently), biopsy shows villous atrophy, bloods show endomysial antibody **Management:** life-long gluten-free diet - risk of bowel malignancy if patients do not adhere to gluten-free diet

Answer 38

Weight \>98th centile for their age

Answer 39

BMI between 91st-98th centile

Answer 40

HTN, insulin resistance, T2DM, sleep apnoea, orthopaedic problems and low self-esteem

Answer 41

Education education education Don't encourage a child to lose weight, encourage them to live a healthy life and gow into their weight

Answer 42

Nutritional intake insufficient to meet the needs of the body e.g. growth and physiological function Major problem in low income countries but also seen in higher income countries where nutritional insufficiency occurs due to chronic illness Can be split into macro and micro nutrient deficiency

Answer 43

Vitamin D \>\> Rickets Iron \>\> iron deficiency anaemia

Answer 44

Needed for intestinal absorption of calcium and bone mineralisation Some vitamin D is taken from the diet but the most is made in the skin following UV exposure Lack of sun = lack of vitamin D = lack of calcium = lack of bone mineralisation 40% \<5yrs are vitamin D deficient Supplementation advised for pregnant/ breastfeeding women and children between 6 months - 5yrs who drink \<500ml milk daily Severe deficiency = Ricketts, seizures, cariodmyopathy

Answer 45

Caused by lack of vitamin D Growth plates are poorly mineralised and bony deformity occurs Bowed legs, rachitic rosary (beading along ribs due to expansion of costochondral junctions), tender + swollen joints (esp. ankles and wrists) Can cause delayed walking, waddling gait, poor growth, softning of skull, symptoms of hypocalcaemia

Answer 46

Usually presents with bleeding Newborn babeis have low vitamin K levels and breast milk is low in it so babies injected immediately after birth to prevent haemorrhagic disease of newborn Older children may be at risk of vitamin K deficiency if they have liver disease/ malabsorption

Answer 47

AKA vitamin K deficiency bleeding Preents with intracranial haemorrhage Vitamin K deficiency leads to the risk of blood coagulation problems due to impaired production of clotting factors II, VII, IX, X, protein C and protein S by the liver Uncommon in developed countries due to IM injection after birth

Answer 48

Rare in healthy children but can occur in those with poor small intestine absorption e.g. Crohns Causes poor growth, diarrhoea and impaired immunity **_Acrodermatitis enteropathica_** = autosomal recessive condition leading to impaired absorption of zinc \>\> causes rash around mouth and perineum + alopecia + chronic diarrhoea + FTT in infancy - Responds well to zinc supplementation

Answer 49

Inadequate intake: inadequate spply, anorexia, physical feeding difficulties e.g. cerebral palsy Malabsorption Excessive nutrient loss: diarrhoea Increased metabolic demands: congenital heart disease, CF, hyperthyroidism Consequences: lack of energy, increased susceptibility to illness and infection, poor growth, poor outcomes

Answer 50

Acute hepatitis: non-specific symotms e.g. fever, diarrhoea, vomiting, flu-like, jaundice 20-30% have hepatosplenomegaly, bloods show raised liver enzymes Generally self-limiting but can develop into liver failure

Answer 51

Viral (A-E), EBV and CMV Bacteria, fungal, parasitic Drugs: paracetamol Genetic: Wilson's, a anti-trypsin deficiency, haemochromatosis Autoimmune hep, lupus

Answer 52

Rare disease that causes liver damage associated with the use of aspirin in children \>\> hence aspirin not being prescribed to children unless for Kawasaki's disease

Answer 53

Right lower lobe pneumonia

Answer 54

1/2000 newborns Herniation of abdominal contents into chest cavity due t incomplete diaphragm formation Consequences: lung hypoplasia, HTN, resp. distress shortly after birth Most common = left side (85%) = Bochdalek hernia Only 50% survive dspite intervention

Answer 55

USS - shows a target-like mass

Answer 56

Empty RLQ due to intussusception seen on AXR Mass may be felt in RUQ

Answer 57

The longer the delay in treatment the longer it has to be treated for * Anal fissure * Haemorrhoids (rare in children) * Rectal prolapse * Megarectum * Faecal impaction and soiling * Volvulus * Distress and psychosocial issues

Answer 58

* Children who have experienced pain when passing stools can adopt a retentive posture - straight legs on tiptoes with an arched back * Bowel habit diary - easier to manage if there is a clear picture * Rewards * Diet and lifestyle advice * Disimpaction regime: escalating dose of macrogol, if this fails add a stimulant e.g. senna. Avoid suppositories/ enemas in primary care * Secondary care: manual evacuation, polyethylene glycols via NG for whole gut lavage, antegrade colonic enema, psychological and behavioural therapies

Elimination problem Flashcards

Congenital disorders, vomiting, constipation, diarrhoea