Gastro/Liver Flashcards
(147 cards)
1
Q
GI CF management
A
Monitoring appetite, stools and GORD
Replace pancreatic enzymes (e.g. pancreatin, CREON)
+ PPI to improve alkaline environment for pancreatin to do its thing
Nutrition - increased caloric intake (150%) - consider overnight feed by gastrotomy
Vitamins ADEK
Ursodeoxycholic acid (improve bile flow)
Ranitidine/omeprazole to help with GORD symptoms
2
Q
Four gastro causes of recurrent abdominal pain
A
IBD IBS Gastritis/dyspepsia Abdominal migraine (Recurrent abdominal pain (RAP))
3
Q
IBS mx
A
Diet and lifestyle modification (avoiding triggers, stress coping strategies)
Antispasmodic (e.g. Buscopan)
If mainly diarrhoea: Antidiarrhoeals (e.g. loperamide)
If mainly constipation: Laxatives
TCA/SSRI
CBT/hypnotherapy
4
Q
Conservative measures IBS
A
Diet and lifestyle modidication
CBT
Hypnotherapy
5
Q
Which type of GI ulcers are more common in children?
A
Duodenal
6
Q
How is H.pylori diagnosed?
A
C13 breath test, stool antigen
Gastric antral biopsy
7
Q
Mx acute gastritis
A
Endoscopy +/- blood transfusion
Lansoprazole
8
Q
Mx chronic gastritis. Next steps if failure to respond
A
If H.pylori - triple therapy:
- PPI
- Clari
- Amox
If fail to respond = upper GI endoscopy
9
Q
Dyspepsia with normal biopsy
A
Functional dyspepsia
10
Q
Where is the pain loated in abdominal migraines?
A
Central, midline
11
Q
Presentation abdominal migraine
A
Central pain
Vomiting
Pallor
Associated with headache migraines
Personal/FHx migraines
12
Q
What percentage of IBD patients prsent in childhood?
A
25%
13
Q
What is recurrent abdominal pain defined as?
A
More than three months of abdominal pain sufficient to disrupt normal activities
14
Q
Non gastro causes of recurrent abdo pain
A
Urinary (UTI)
Gynae (dysmenorrhoea, PID, cysts)
Psychosocial (RAP)
Hepatobiliary (hepatitis, stones, pancreatitis)
15
Q
Commonly affected areas in Crohn’s
A
Distal ileum to proximal colon
16
Q
Presentation of Crohn’s
A
Bloody diarrhoea
Abdo pain
Weight loss
Pallor
FTT
17
Q
Clinical features of Crohn’s (+ SIGNS)
A
Bloody diarrhoea
Abdo pain
Weight loss
Pallor
FTT
Erythema nodosum Fissures Fistulae Tags Ulcers
18
Q
Investigations for Crohn’s
A
Bloods (raised CRP/ESR, low Hb, low albumin)
Small bowel biopsy w/ histology (non-caseating epthelioid cell granulomata)
19
Q
Management of Crohn’s
A
Conservative: stop smoking
Medical:
- Steroids - budenoside (induce and maintain remission)
- Immunosuppressants: azathioprine/methotrexate
- Biologics - infliximab (with abx)
Nutritional support. Enteral supportive feed if necessary.
Ca, VitD, B12, ferritin
20
Q
Presentation of UC
A
- Bloodu, mucous diarrhoea
- Abdo pain (colicky)
Weight loss
Growth failure
Erythema nodosum
Clubbing
21
Q
Ix for UC
A
Bloods
Colonic biopsy - crypt damage and abscesses in the mucosa
22
Q
How is the severity of UC assessed?
A
Paediatric Ulcerative Colitis Activity Index
Higher score = increased severity
23
Q
Mx of UC (mild/mod/severe/steroid dependent)
A
Mild - mesalazine (induce and maintain remission). Oral pred if relapse Mod - Oral pred for 2-4 weeks then taper Mesalazine Severe - MEDICAL EMERGENCY. IV methylprednisolone Parenteral nutrition Surgery
Steroid dependent - infliximab
24
Q
Features of malabsorptive disease
A
FTT / poor growth
Abnormal stools
Specific nutrient deficiencies
25
Four examples conditions resulting in malabsorption
Coeliac
Biliary atresia
Pancreatic exocrine dysfx (e.g. CF)
Short bowel syndrome
26
Presentation of coeliac
```
Poor growth/FTT
Buttock wasting
Abnormal/offensive/fatty stools
Abdominal distension
General irritability
Pallor
```
Rash - dermatitis herpetiformis
27
Age of presentation coeliac
8-24 months
28
Pathophysiology of coeliac
Non-IgE reaction against gliadin protein in gluten.
| Immune response in the mucosa of the proximal small intestine
29
Which part of the bowel is most affected in coeliac?
Proximal small bowel (mucosa)
30
Which other conditions is coeliac associated with (and should children with coeliac be screened for)?
T1DM
Hypothyroid
Down's
31
Ix for suspected coeliac
Bloods (anti-TTG Abs, Endomysial antibodies) - in some cases these are now sufficient for diagnosis
Small bowel (jejunum) biopsy - villous blunting, crypst hyperplasia
Removal of gluten = catch up growth
32
Mx of coeliac
MDT
Remove gluten from diet (with dietary advice from dietician)
Calcium, vitaminD, iron
Regular monitoring of height, weight, development
33
How can coeliac patients' diets be checked?
Serology
34
Complications of coeliac disease
Malnutrition
EATL lymphoma
Osteoporosis
35
Causes of diarrhoea
```
Gastroenteritis
Toddler's diarrhoea
IBD
Coeliac
IBS
Medications
Food allergy/intolerance
```
36
Commonest cause persistent loose stoolin preschool children
Toddler's diarrhoea
37
Presentation toddler's diarrhoea
Persistent loose stool
Undigested veg
Varying consistency
Child is otherwise WELL AND THRIVING
38
Pathophysiology of toddler's diarrhoea
Underlying delay in intestinal maturity
39
Complication of toddler's diarrhoea
Achieving faecal continence may be delayed
40
Mx toddler's diarrhoea
More fat and fibre in diet to slow gut transit
41
Causes of constipation in infants
```
Hirschsprung's
Atresia
Hypothyroid
Hypocalcaemia
Anorectal abnormalities
```
42
Causes of constipation in children
Dehydration
Poor diet
Toilet training issues
Stress
Hypothyroid
Hypocalcaemia
43
Constipation presentation
Infrequent passage hard, dry faeces
Accompanied by straining/pain
Palpable abdo mass
May have overflow diarrhoea
44
Red flag symptoms associated with constipation
Neuro signs - SCC/SOL
FTT
Gross distension
Anal sx - sexual abuse?
45
Constipation mx
Movicol (osmotic)
Diet
Increased fluid
Behavioural interventions - regular toileting, reward system, bowel habit diary
CBT
Family therapy
46
Four types of laxative
Osmotic - movicol
Stimulant - senna
Bulk-forming - fybogel
Stool softener - docusate sodium
47
Features of overflow diarrhoea
Faecal incontinence
| Foul smelling diarrhoea
48
Mx anal fissure
Increase fibre
Increase fluids
Stool softeners (e.g. docusate sodium)
Topical GTN intra-anally
Analgesia
Anal hygiene
AVOID stool withhoding
If not healed after 2 weeks, come back
49
Causes vomiting in a neonate
```
Hirschsprung's
Pyloric stenosis
Allergy
Atresia
Sepsis
CAH
Overfeeding
Meconium plug
Intussusception
Malrotation/volvulus
GORD
```
50
Pathophysiology of Hirschsprung's
Absence of myenteric plexus in rectum --> colon
51
Presentation of Hirschsprung's
Failure to pass meconium in first 48 hours of life
Gross abdominal distension
Eventually bilious vomiting
52
Mx Hirschsprung's
Bowel irrigation
| Surgical - colostomy followed by anorectal pull through: anastamoses of normally innervated bowel to anus
53
Complications Hirschsprung's
Acute enterocolitis (15%)
54
Is Hirschsprung's more common in males or females?
Males (4:1)
55
Presentation of pyloric stenosis
Projectile vomiting
HUNGER (will keep attempting to feed until they are dehydration when they will no longer attempt)
Weight loss
- Peristalsis across abdomen
- Mass RUQ
56
Age of presentation pyloric stenosis
2-7 weeks
57
Which infants more commonly get pyloric stenosis
Males
(Particularly first born)
Maternal GDM
58
Pathophysiology of pyloric stenosis
Hypertrophy of pyloric muscle = gastric outlet obstruction
59
Ix for pyloric stenosis
Gas (often metabolic alkalosis)
- Hypochloraemic, Hyponatraemic, Hypokalaemic
USS
60
What acid-base disturbance occurs as a result of pyloric stenosis?
Metabolic alkalosis
61
Mx pyloric stenosis
IV fluid resuscitation (severe dehydration)
- 1.5x maintenance with dextrose and saline
- Add potassium once urine output is adequate
Surgery - Ramstedt pyloromyotomy - dividing hypertrophied muscle (not mucosa)
62
What must be done before surgery to correct pyloric stenosis?
IV fluid resuscitation and electrolye balancing
63
Presentation duodenal atresia
Persistent bile stained vomit
Meconium may be passed, but then with subsequent delay
Abdominal distension
64
Which genetic abnormality is duodenal atresia associated with?
Down's syndrome
65
Do higher or lower lesions present earlier in duodenal atresia?
Higher
66
Mx duodenal atresia
```
NBM
D&S (NGT)
IV fluid resuscitation
Surgery
+/- abx
```
67
Intrauterine trachy-oesophageal fistulae
Polyhydramnios
68
Presentation of trachy-oesophageal fistulae
Persistent drooling
Vomiting
Aspiration
69
Which multi-system syndrome are trache-oesophageal fistulae associated with?
VACTERL
```
Vertebrae
Anal atresia
Cardiac
Trache-oEsophageal fistula
Renal
Limb
```
70
Risk factors for GORD (young infants)
Short oesophagus
Horizontal posture
Fluid diet
71
Complications of GORD
FTT
Recurrent aspiration
Oesophagitis -- IDA
Sandiser syndrome - dystonic neck posture
72
When do most GORDs resolve spontaneously by?
1 year
73
Ix GORD
24hr pH monitoring
Endoscopy
(USS to rule out pyloric stenosis, atresia)
74
Mx GORD
REASSURE
Consider (breast feeding) assessment
1) Mechanical/conservative - vertical position when feeding, winding. Feeds little and often. Thicken feeds.
2) Baby gaviscon / alginate therapy
3) PPI trial
4) Enteral feeding / Nissen fundoplication if FTT
75
Pathophysiology of intussusception
Invagination of proximal bowel into distal bowel causes obstruction
76
Where does intussusception often take place
Ileo-caecal valve
77
Age of presentation of intusussception
3mos - 2 years
78
What is the commonest cause of GI obstruction after the neonatal period?
Intussusception
79
Complications of intussusception?
Engorgement
Bleeding
Ischaemic bowel -- enterocolitis
80
Presentation of intussusception
```
Paroxysmal, severe colicky pain
Pallor, increasingly lethargic
Bile stained vomit
Refusal of feeds
Sausage-shaped palpable mass on abdomen
REDCURRANT JELLY STOOL
```
81
What diagnosis is redcurrant jelly stool indicative of?
Intussusception
82
Ix intussusception
USS: target lesion
AXR: distended small bowel loops. Absence of gas in distal colon
Bloods: shock
83
Mx intussusception
ABCDE
(IVI and NG tube aspiration)
AIR INSUFFLATION
Broad spec abx - clindamycin + gentamicin
Surgery if insufflation fails
84
When is air insufflation not appropriate in treating intussusception?
If there are signs of peritonitis, perforation, hypovolaemic shock
85
Percentage of children with Meckel's diverticulum
2%
86
Presentation of Meckel's diverticulum
Severe PR bleed - not bright red nor malaena
| intussusception/malrotation
87
Mx Meckel's diverticulum
Surgical excision
Adhesion lysis
+/- bowel resection
88
What is a Meckel's diverticulum?
Ileal remnant of vitello-intestinal duct
89
Presentation of malrotation
Intestinal obstruction with reduced blood supply - bile stained vomit, distended abdomen
90
Age of presentation malrotation
Usually first 1-3 days of life
91
Ix malrotation
Upper GI contrast study
92
Mx malrotation if evidence of vascular compromise
Emergency laparotomy
93
Mx malrotation
Surgery: Ladd procedure - detort bowel, divide, Ladd bands
Normally also remove appendix to avoid future confusion
Abx: cefalozin
94
Appendicitis presentation
Abdo pain (starting umbilical, localise to RIF)
Anorexia
Vomiting
Oral fetor
Low grade fever
McBurney's/Rovsing's signs
95
Ix appendicitis
Bloods (raised WCC, CRP)
BC
USS - inflammed, thickened. Increased blood flow on dopplers.
96
Mx appendicitis
SURGERY
NBM
IVI fluid resuscitation
Abx: cefalozin
97
Mx mesenteric adenitis
Self resolving
98
Presentation mesenteric adenitis
Non specific abdo pain
| Often accompanied by URTI and cervical lymphadenopathy
99
Commonest viral cause of gastroenteritis
Rotavirus
100
Ix gastroenteritis
Bloods
BC
Stool sample
Monitor weight loss
101
Ix post gastroenteritis syndrome
Positive clinitest
102
Post gastroenteritis syndrome
Temporary lactose intolerance
103
Mx gastroenteritis
Fluid replacement
104
Presentation of hepA
Mild illness - lethargy, some nausea, malaise
105
Management of hepA
Notify HPU
Supportive (for pain, nausea, itch)
Close contacts should be vaccinated within 2 weeks of illness starting
106
How is hepB transmitted?
```
Vertical from mother
Horizontal from families
Blood products
Needlestick injuries
Renal dialysis
(Sexual transmission in adults)
```
107
Mx of acute hepatitis B
Notify HPU
Supportive
Anti-virals e.g. tenofovir disoproxil
108
Mx of chronic hep B
Notify HPU
Supportive
Anti-virals - interferon, tenofovir disoproxil
109
What % of asymptomatic carriers develop chronic HBV infection?
30-50%
110
How cna hepB be prevented?
Antenatal screening
Antiviral therapy for HBsAg positive mothers
HepB vaccine for infants born to HBsAg positive mothers
+ immunoglobulin if mother is HBeAg positive
111
Commonest hepatitis C infection
Chronic carrier
112
% of chronic hepC carriers who go onto have HCC/cirrhosis
20-25%
113
Treatment chronic hepC
Notify HPU
S/c peg interferon and ribavarin
114
Commonest causes of acute liver failure, including three most common
- PARACETAMOL OD
- NON-A TO G HEPATITIS
- METABOLIC
- Hep ABC
- AI hep
- Other poisons
115
Pathophysiology of acute liver failure
Massive hepatic necrosis = reduced liver function +/- encephalopathy
116
Presentation of acute liver failure
Jaundice
Bleeding
Hypoglycaemia
Electrolyte disturbances
Encephalopathy
- Irritability/confusion/drowsiness
- Aggressive/difficult behaviour
117
Complications of acute liver failure
```
Hepatic encephalopathy
Cerebral oedema
Bleeding
Sepsis
Pancreatitis
```
118
Mx of acute liver failure (think of liver fx)
```
Hypoglycaemia - IV dextrose
Haemorrhage - IV vit K, cryo, FFP
Oedema - fluid restriction/mannitol diuresis
Sepsis risk - broad spec abx
Gastritis - PPI/H2 antagonist
Transplant
```
119
Which features are suggestive of a poor prognosis in acute liver failure?
Shrinking liver
Rising BR with falling transaminases
Worsening coagulopathy
Coma
120
Causes of chronic liver disease
```
Chronic hepatitis (B,C, AI, PSC, drugs)
Wilson's
alpha1-antitrypsin
CF
Neonatal liver disease
Bile duct lesions
```
121
Which drugs particularly can predispose to chronic liver failure?
Nitrofurantoin
| NSAIDs
122
Commonest causes of chronic liver disease
Hep B C
| AI hep
123
Presentation of chronic liver failure
Lethargy
Malnutrition
Insidious hepatosplenomegaly
124
Age of presentation AI hepatitis
7-10 years
125
Is AI hepatitis more common in boys or girls?
Girls
126
Presentation of AI hepatitis
Lethargy, malnutrition
Liver signs
+ other AI signs - rash, arthralgia, haemolytic anaemic, nephritis
127
Investigations for AI hepatitis
Bloods: hypergammaglobulinaemia (IgG>20)
+ve autoantibodies
Reduced serum C4
Histology
128
Mx of AI hepatitis
Prednisolone
Azathioprine
If PSC: ursodeoxycholic acid
129
Mx of PSC
Ursodeoxycholic acid
130
Wilson's mode of inheritance
AR
131
Pathophysiology of Wilson's
Reduced copper excretion in bile, reduced caeruloplasmin = copper deposits in liver, brain, kidney, cornea
132
Ix Wilson's disease
Urinary copper excretion (particularly raised after chelation)
133
Mx Wilson's disease
Zinc - reduces copper absoprtion in intestine
Trientine - increases copper excretion in urine
Pyridoxine - vitB6 prevents peripheral neuropathy
134
Mx of NAFLD
Weight loss - diet, exercise, bariatric surgery
Treat underlying insulin resistance
Vitamin E
135
Mx of cirrhosis/portal HTN (think ascites)
Na/fluid restriction
Diuretics
HAS/clotting factors
Paracentesis
NUTRITIONAL SUPPORT
136
What nutritional support to patients with cirrhosis need?
Vits ADEK
| Increased calories
137
Management for encephalopathy
Supportive
Aim to reduce nitrogenous load -- protein restricted diet,
lactulose
138
Why might intussusception occur after a febrile illness?
Enlarged Peyer's patches acting as the lead point for intussusception
139
What may be the cause of recurrent intussusception ?
Pathological lead point, e.g. Meckel's diverticulum
140
Should CF children have increased or reduced caloric intake?
Increased (150%)
141
HLA associated with coeliac?
HLA DQ8
142
What happens if you remove the gluten from the diet of a child with FTT caused by coeliac?
Catch up growth
143
Why is increased fat diet recommended in toddler's diarrhoea?
Slow gut transit
144
What should be monitored in a child with gastroenteritis?
Weight loss (dehydration)
145
Features of post- gastroenteritis syndrome?
Temporary lactose intolerance
| +ve clinitest
146
Normal hepB immunisation schedule
8/12/16 weeks
147
HepB immunisation schedule if infected mother (HBsAg +ve)
4/12/16 weeks
AND
Birth, 4 weeks, 1 year
