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Gastro Flashcards

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1
Q

Explain Posseting, Regurgitation and Vomiting

A

Posseting = small amounts of milk which accompany the return of swallowed air

Regurgitation = Larger, more frequent losses

Vomiting = forceful ejection of gastric contents

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2
Q

Causes of Vomiting in infants?

A

Gastro-oesophageal reflux

Feeding problems

Infection ( gastroenteritis, respiratory tract, whooping cough, urinary tract, meningitis)

Dietary protein intolerances

Intestinal obstruction ( pyloric stenosis, atresia, malrotation, volvulus, hirschsprung disease)

Inborn errors of metabolism

Congenital adrenal hyperplasia

Renal Failure

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3
Q

Causes of vomiting in Preschool children

A

Gastroenteritis

Infection ( resp tract, urinary tract, meningitis, whooping cough)

Appendicitis

Intestinal obstruction ( intussusception, malrotation, volvulus, adhesions, foreign body)

Raised ICP

Coeliac Disease

Renal Faiure

Inborn erros of metabolism

Torsion of testes

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4
Q

Causes of vomiting in school-age children?

A

gastroenteritis

infection ( consider pyelonephritis, septicaemia, meningitis)

peptic ulcer

appendicitis

migraine

raised ICP

coeliac disease

renal failure

diabetic ketoacidosis

alcohol/drugs

cyclical vomiting syndrome

bulimia/anorexia

pregnancy

torsion of the testes

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5
Q

What are the two most common causes of chronic vomiting in infants?

A

Gastro-oesophageal reflux

Feeding problems (force feeding/ overfeeding)

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6
Q

If vomiting in infants occurs with other symptoms such as fever, diarrhoea, runny nose or cough, what should be considered?

A

Gastroenteritis or Resp tract infection

but also consider UTI and Meningitis

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7
Q

What should be excluded if an infant is projectile vomiting around age 2-7 weeks?

What should be excluded if it is bile-stained? What further assessments should be done?

A

Pyloric Stenosis

Intestinal obstruction ( intussusception, malrotation and a strangulated inguinal hernia)

Assess for dehydration and shock

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8
Q

What is the cause of gastro-oesophageal reflux in infants?

A

Inappropriate relaxation of the lower oesophageal sphincter as a result of functional immaturity

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9
Q

When does gastro-oesophageal reflux in infants normally resolve and why?

A

12 months

  1. maturation of the sphincter
  2. upright posture
  3. more solids in diet
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10
Q

What complications are associated with gatro-oesophageal reflux?

A
  1. Failure to thrive
  2. Oesophagitis
  3. Recurrent Pulmonary Aspiration (can lead to pneumonia, cough or wheeze)
  4. Dystonic neck posturing
  5. Apparent life-threathening events
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11
Q

Which infants are more likely to develop severe reflux?

A

Children with cerebral palsy

Preterm-infants (esp if they have bronchopulmonary dysplasia)

Following oesophageal atresia or diaphragmatic herna surgery

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12
Q

What investigations and management for gastro-oesophageal reflux?

A

Invest - nnormally clinical, however oesophageal pH monitoring can be used and endoscopy to idenitfy oesophagitis

Manage - parental assurance and thickening agents

  • if bad can use H2 receptor antagonists and PPIs
  • surgery considered in very bad cases
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13
Q

What happens as a consequence of severe vomiting due to pyloric stenosis?

A

hypochloraemic metabolic alkalosis

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14
Q

How can pyloric stenosis be diagnosed?

A

Examination - feed baby milk…..pyloric mass can be felt like an olive in the right upper quadrant

ultrasound examination also helpful

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15
Q

What must be done before a pyloromyotomy can be carried out?

A

Ensure that any fluid and electrolyte disturbances have been corrected

0.45% saline and 5% dextrose with potassium supplements

Then the pyloromyotomy procedure can be carried out

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16
Q

What can be some causes of sudden onset continuous crying in an infant?

A
  1. UTI
  2. Ear infection
  3. Fracture
  4. Torsion of Testis
  5. Meningitis
  6. Oesophagitis
  7. Coeliac disease
  8. Constipation
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17
Q

How does infant colic present?

A

Paroxysmal, inconsolable crying
drawing up of knees
excessive flatus

presents in 40% of babies and resolves by 4 months

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18
Q

If Infant Colic presents more severe and persistent that normal what could it be?

A
  1. Cow’s milk protein allergy

2. Gastro-oesophageal reflux

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19
Q

What are some less common causes of acute abdominal pain?

A
  1. lower lobe pneumonia may cause referred pain to abdomen
  2. primary peritonitis seen in patients with ascites (nephrotic syndrome/ liver disease)
  3. Can consider things such UTI and pyelonephritis
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20
Q

What is the commonest cause of childhood abdominal pain?

A

Acute Appendicitis

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21
Q

Symptoms of acute appendicitis?

A

anorexia

vomiting

abdo pain that starts centrally and moves towards right iliac fossa

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22
Q

Signs of acute appendicitis?

A

flushed face

oral fetor

low grade fever

abdo pain aggravated by movement

persistent tenderness with guarding in Mcburneys point

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23
Q

What is non-specific abdominal pain and mesenteric adenitis?

A

Abdominal pain which resolves in 24-48 hrs, often accompanied by an URTI and cervical lymphadenopathy

Identified during laparoscopy/laparotomy by large mesenteric nodes when the appendix is normal

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24
Q

What medical causes must be considered in older children and adolescents when presenting with abdominal pain?

A

Lower Lobe Pneumonia
Diabetic Ketoacidosis
Hepatitis
Pyelonephritis

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25
When is intussusception in infants most common?
2-24 months | most common cause of intestinal obstruction
26
What are clinical features of intussusception?
paroxysmal, colicky pain with pallor, abdominal mass, redcurrant jelly stool
27
What imaging is used to diagnose intussusception? what would you see?
Abdominal X-Ray = distended small bowel and absence of gas in distal colon/rectum
28
Treatment options for intussusception?
IF there is NO peritonitis = rectal air insufflation and abdominal ultrasound to check response If unsuccessful operative reduction
29
What is Meckel's Diverticulum?
Ileal remnant of vitellointestinal duct
30
Anatomically how does malrotation occur?
If small bowel mesentery is not fixed at the duodenojejunal flexure or the ileocaecal region
31
How does volvulus due to malrotation present?
blood in gastric aspirate or stool bilious vomiting abdo pain tenderness
32
What urgent investigation must be performed in any child presenting with bilious vomiting?
Upper GI contrast study
33
What is recurrent abdominal pain?
recurrent pain, sufficient to interrupt normal activities that last atleast 3 months affects 10% school-age children normally pain occurs around umbillicus
34
What investigations would you perform on a child presenting with recurrent abdominal pain?
Full Hx and Exam 1. Perineum for anal fissures 2. Check child's growth 3. Urine microscopy and culture (UTI) 4, Abdo USS (exclude gall stone and PUJ obstruction)
35
What is long-term prognosis for recurrent abdominal pain?
50% will resolve rapidly 25% will take months to resolve 25% will develop migraine, IBS or functional dyspepsia in adulthood
36
What is the most common cause of gastorenteritis in developed countries?
Rotavirus | also can be adenovirus, norovirus, calicivirus
37
While less common, how would a bacterial form of gastroenteritis present? what is the most common organism?
Blood in the stool Campylobacter Jejuni other bacteria : cholera & enterotoxigenic E.coli
38
What infections could be mistaken as gastroenteritis?
septicaemia, meningitis, resp. tract infection, otitis media, Hep. A, UTI
39
What surgical disorders could be mistaken as gastroenteritis?
pyloric stenosis, intussusception, acute appendicitis, Hirschsprung
40
What metabolic disorders could be mistaken as gastroenteritis?
diabetic ketoacidosis
41
What groups of children are at increased risk of dehydration?
1. under 6 months of age 2. born with low birthweight 3. vomited 3 or more times in last 24 hours 4. if they cant tolerate extra fluids 5. if they have malnutrition
42
Why are infants at greater risk of dehydration?
1. have greater surface area to weight ratio 2. have higher basal fluid requiremnets 3. immature renal tubular reabsorption
43
When can dehydration be detected clinically?
>5% loss of bodyweight >10% loss = SHOCK
44
What is isonatraemic dehydration?
When losses of water are proportional to losses in sodium
45
How does hyponatraemic dehydration occurs? What complications can be caused by it?
When in isonatraemic dehydration the infant consumes water or hypotonic solution, causing increase in water but not sodium This leads to extracellular water moving into cells. In the brain this increases it's volume causing convulsions Extracellularly, this loss of water further compounds the effects of shock
46
What causes hypernatraemic dehydration?
High insensible water loss ( high fever, hot dry environment, Low-sodium diarrhoea
47
What are signs of hypernatraemic dehydration?
depression of fontanelle decreased tissue elasticity sunken eyes *hard to diagnose in fat babies
48
What complications can arise from hypernatraemic dehydration?
Brain/cerebral shrinkage - jittery movements, increased muscle tone, hyperreflexia, seizures, small cerebral hemmorhage Transient hyperglycemia in some babies
49
What are red flag symptoms of clinical dehydration?
Appears unwell or deteriorating Altered responsiveness (irritable, lethargic) Sunken Eyes Tachycardia Tachypnoea Reduced Skin Turgor Also (reduced urine output, dry mucous membranes
50
What investigations should be carried out for gastroenteritis?
Stool Culture U&Es if Abx taken take a blood culture
51
What is management for a child who is clinically dehydrated?
Oral rehydration solution - fluid deficit replacement (50ml/kg) over 4 hours + maintenance fluids IF keeps vomiting consider ORS by NG
52
What is management for a child who is in shock?
IV therapy - 0.9% NaCl If patient improves Replace fluid deficit : If initially shocked give 100ml/kg If not shocked give 50ml/kg
53
What is post-gastroenteritis syndrome?
Following gastroenteritis, introdcution of normal diet causes diarrhoea. This is caused by lactose intolerance and diagnosed by a postive Clinitest, indicating non-absorbed sugar in the stool To manage put them on ORS for 24 hrs then restart normal diet
54
What are 3 indications of malabsorption?
1. Abnormal Stools 2. Failure to thrive (in most) 3. Specific nutrient deficiencies
55
What causes coeliac disease?
Gliadin component of Gluten
56
How does coeliac disease present?
Classically - failure to thrive, abdominal distension, buttock wasting, general irritability More commonly these days - mild, non-speccific GI symptoms, anaemia (iron/folate), growth failure
57
What groups of children are at higher risk of coeliac disease?
Type 1 Diabetes Autoimmune Thyroid Down's 1 degree relative with known disease
58
How do you diagnose Coeliac disease?
Gold Standard - biopsy = muscosal changes seen ; 1. increased intraepithelial lymphocytes 2. villous atrophy 3. crypt hypertrophy
59
What can help with toddler diarrhoea and what makes it worse?
fats can help fruit juices high in non-absorbable sorbitol
60
What to consider if a child has diarrhoea and one of the following? a) failure to thrive b) following gastroenteritis c) following bowel resection d) otherwise well
a) coeliac or cow's milk protein allergy b) post-gastroenteritis lactose intolerance c) cholestatic liver disease, exocrine pancreatic dysfunction, malabsorption d) toddler diarrhoea
61
How does Crohn's disease present?
Classically : abdominal, diarrhoea, weight loss General : Fever, lethargy and weight loss Extra-Intestinal : oral lesions, perianal skin tags, uveitis, arthralgia and erythema nodosum
62
It adolescents what can the symptoms of Crohn's normally be mistaken for?
psychological problems/ anorexia
63
What would you use to diagnose Crohn's and what would you expect to see?
Endoscopy - non-caseating epitheloid cell granulomata in small bowel - narrowing, fissuring, muscosal irregularities and bowel wall thickening
64
How would you treat Crohn's?
To achieve remission - normal diet replaced with whole protein modular feeds For long-term treatment - immunosuppresants (azathioprine, mercaptoprine or MTX) anti-tumour necrosis factor agents (infliximab/adalimumab) *overnight ng/gastromy feeds may be needed for growth correction Surgery - needed to remove obstruction, fistulae and abscess formation
65
How would Ulcerative Colitis present?
rectal bleeding, diarrhoea and colicky pain weight loss and growth failure extra-intestinal - erythema nodosum and arthritis
66
Diagnosis of Ulcerative Colitis?
Endoscopy mucosal inflammation, crypt damage and ulceration
67
What form of UC is normally seen in children?
Pancolitis - 90% of children in adults normally restricted to distal colon
68
Treatment for UC?
Aminisalicylates Systemic Steroids (azathioprine) Surgery - Colectomy
69
Why are regularly colonoscopic screenings required after diagnosis with UC?
adenocarcinoma risk
70
What is Hirschsprung diseasE?
absence of ganglioncells from myenteric and submucosal plexus in part of the large bowel
71
Which areas of the bowel are affected by Hirschsprung?
75% rectosigmoid | 10% entire colon
72
How does Hirschprung's disease present?
In neonatal period - intestinal obstruction and failure to pass meconium, abdominal distension and bile-stained vomiting In later childhood - chronic constipation, abdominal distension w/o soiling and growth failure * occasionally severe, life-threathening Hirschsprung enterocolitis sometimes due to clostridium difficile
73
Diagnosis of Hirschsprung's?
Rectal biopsy (absence of ganglion cells)
74
Management of Hirschsprung's?
Surgical - colostomy and anastomising normal innervated bowel

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