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Paediatrics > Gastroenterology > Flashcards

Gastroenterology Flashcards

1
Q

What are the typical features suggesting constipation?

A 
Less than 3 stools a week
Hard stools difficult to pass
Rabbit dropping stools
Straining and painful
Abdominal pain
Holding abnormal posture - retentive posturing
Rectal bleeding with hard stools
Overflow soiling with faecal impaction
Hard stools palpable in abdomen
Loss of sensation of need to open bowels
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2
Q

What is encopresis?

A

Faecal incontinence
Not considered pathological until 4 years of age
Sign of chronic constipation because rectum is stretched and loses sensation
Loose stools leak out

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3
Q

What are rarer causes of encopresis?

A 
Spina bifida
Hirschsprung's disease
Cerebral palsy
Learning disability
Psychosocial stress
Abuse
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4
Q

What lifestyle factors can cause constipation?

A 
Habitually not opening bowels
Low fibre diet
Poor fluid intake and dehydration
Sedentary lifestyle
Psychosocial problems
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5
Q

What are secondary causes of constipation?

A 
Hirschsprung's
Cystic fibrosis - meconium ileus
Hypothyroidism
Spinal cord lesions
Sexual abuse
Intestinal obstruction
Anal stenosis
Cows milk intolerance
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6
Q

What are the red flags indicating a serious condition causing constipation?

A

Not passing meconium within 48 hours of birth - CF or Hirschsprung’s
Neurological signs or symptoms - lower limbs
Vomiting - obstruction
Ribbon stool - anal stenosis
Abnormal anus
Abnormal lower back or buttocks
Failure to thrive - coeliac, hypothyroid, safeguarding
Acute severe abdominal pain and bloating

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7
Q

What are the complications of constipation?

A 
Pain
Reduced sensation
Anal fissures
Haemorrhoids
Overflow and soiling
Psychosocial morbidity
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8
Q

What is the NICE guidelines on management of constipation if faecal impact is present?

A

Polyethylene glycol and electrolytes - Movicol Paediatric Plan
Add stimulant if does not lead to disimpaction after 2 weeks
Substitute with osmotic laxative e.g. lactulose if not tolerated

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9
Q

What is the maintenance therapy for constipation?

A

Movicol
Add stimulant laxative if no response
Substitute stimulant if not tolerated
Continue at maintenance dose for several weeks after regular bowel habit established

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10
Q

What are the red flag clinical features in the vomiting child?

A

Bile stained - obstruction
Haematemesis - oesophagi’s, ulceration, oral/nasal bleeding
Projectile - pyloric stenosis
Vomiting at end of coughing - whooping cough
Abdo distention - obstruction
Hepatosplenomegaly - chronic liver disease
Bulging fontanelle or seizures - raised ICP
Failure to thrive - GORD, coeliac

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11
Q

What is GORD?

A

Where contents of stomach reflux through lower oesophageal sphincter
In babies is normal due to immaturity of LOS; provided otherwise well and growing

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12
Q

What is the presentation of GORD?

A 
Signs of problematic reflux:
Chronic cough
Hoarse cry
Distress, crying, unsettled
Reluctance to feed
Pneumonia
Poor weight gain
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13
Q

What advise is given to relieve GORD?

A

Small frequent meals
Burping regularly to help milk settle
Not overfeeding
Keeping baby upright after feeding

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14
Q

Who is more severe GORD a problem in?

A

Children with cerebral palsy or other neurodevelopment disorders
Preterm infants, especially if have bronchopulmonary dysplasia
Following surgery for oesophageal atresia or diaphragmatic hernia

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15
Q

What are complications of GORD?

A 
Failure to thrive
Oesophagitis
Iron deficiency anaemia
Recurrent pulmonary aspiration
Cough or wheeze, apnoea
Dystonic neck posturing
Apparent life threatening events
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16
Q

What investigations are required for GORD?

A

Usually clinical diagnosis
May be indicated if history atypical, complications or failure to respond to tx

24 hour oesophageal pH monitoring
24 hour impedance monitoring
Endoscopy with biopsies for oesophagitis

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17
Q

What is the management of problematic cases of GORD?

A

Gaviscon mixed with feeds
Thickened milk or formula
Ranitidine
Omeprazole

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18
Q

What is Sandifer’s syndrome?

A

Rare condition
Causes brief episodes of abnormal movements associated with GORD

Torticollis - forceful contraction of neck muscles causing twisting of neck

Dystonia - abnormal muscle contractions causing twisting movements, arching of the back, unusual postures

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19
Q

What is colic?

A

Paroxysmal inconsolable crying or screaming
Accompanied with drawing up of the knees
Passage of excessive flatus

Typically occurs in first few weeks and resolves by 4 months

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20
Q

What are surgical causes of acute abdominal pain?

A 
Acute appendicitis
Intestinal obstruction
Intussusception
Inguinal hernia
Peritonitis
Inflamed Meckel's
Pancreatitis
Trauma
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21
Q

What are medical causes of acute abdominal pain?

A 
Gastroenteritis
UTI, pyelonephritis
Hydronephritis
Renal calculus
HSP
DKA
Sickle cell anaemia
Hepatitis
IBD
Constipation
Psychological
Lead poisoning
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22
Q

What are extra-abdominal causes of acute abdominal pain?

A

Upper respiratory tract infection
Lower lobe pneumonia
Torsion of testes
Hip and spine

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23
Q

What is mesenteric adenitis?

A

Swollen inflamed lymph nodes in the abdomen

Diagnosis can only be made definitively if large mesenteric nodes and normal appendix in laparotomy/laparoscopy

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24
Q

What is recurrent abdominal pain?

A

Pain sufficient to interrupt normal activities

Lasts for at least 3 months

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25
Q

What are causes of recurrent abdominal pain?

A 
>90% no cause
IBS, constipation, dyspepsia
Abdominal migraine, ulcers
Dysmenorrhoea, cysts, PID
Psychosocial
Hepatitis, gallstones
UTI, PUJ obstruction
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26
Q

What are signs and symptoms which suggest an organic disease as cause for recurrent abdominal pain?

A 
Epigastric pain at night
Haematemesis - ulcer
Diarrhoea, weight loss
Growth failure
Blood in stools
Vomiting
Jaundice - liver disease
Dysuria, secondary enuresis
Bilious vomiting, abdo distension
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27
Q

What are the symptoms of IBS?

A 
Abdominal pain, often worse before or relieved by defecation
Explosive, loose or mucous stools
Bloating
Feeling of incomplete defecation
Constipation
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28
Q

What is functional dyspepsia?

A

Symptoms of peptic ulceration, abdo pain, nausea
More non specific symptoms
Early satiety
Bloating
Post prandial vomiting
Delayed gastric emptying due to gastric dysmotility

Treatment with hypoallergenic diet

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29
Q

What are the symptoms of duodenal ulcers?

A

Less common in kids
H pylori causes nodular antral gastritis
Epigastric pain waking them at night
FH of peptic ulceration

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30
Q

What conditions can mimic gastroenteritis?

A 
Sepsis, meningitis
RTI, otitis media, Hep A
Pyloric stenosis
Intussusception
Acute appendicitis
NEC
DKA
Haemolytic uraemic syndrome
Coeliac disease
Cow's milk protein intolerance
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31
Q

What is the most frequent cause of gastroenteritis in developed world?

A

Rotavirus

Also adenovirus, norovirus

Bacteria less common, blood in stools if so
Campylobacter jejuni

Shigella - high fever
E coli - dehydrating diarrhoea

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32
Q

What children are at an increased risk of dehydration?

A

Infants under 6 months or low birth weight
Passed >6 diarrhoeal stools in past 24 hours
Vomited three or more times in previous 24 hours
Unable to tolerate fluids
Malnourished

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33
Q

What occurs in hypernatraemic dehydration?

A

Water loss exceeds relative sodium loss
Due to high insensible water losses e.g. high fever, hot/dry environment

Depression of fontanelle
Reduced tissue elasticity
Sunken eyes are all less obvious

Water drawn out of brain and cerebral shrinkage
Leads to jittery movement, increased muscle tone
Hyperreflexia, seizures

34
Q

What are the red flag signs of dehydration suggestive the child is at risk of shock?

A 
Appears unwell or deteriorating
Altered responsiveness
Sunken eyes
Tachycardia
Tachypnoea
Reduced skin turgor
35
Q

How can disorders causing malabsorption manifest in children?

A

Abnormal stools
Failure to thrive or poor growth
Specific nutrient deficiencies

36
Q

What is the cause of coeliac disease?

A

Antibodies:
anti-tissue transglutaminase
anti-endomysial anti-EMA

Inflammation in small intestine, atrophy of intestinal villi

37
Q

What is the presentation of coeliac disease?

A 
Failure to thrive
Diarrhoea
Fatigue
Weight loss
Mouth ulcers
Anaemia secondary to iron, B12 or folate deficiency
Dermatitis herpetiformis

Rarely can present with neurological symptoms e.g. neuropathy, cerebellar ataxia, epilepsy

38
Q

What condition is coeliac often tested alongside at diagnosis?

A

Type 1 diabetes

39
Q

What are the genetic associated with coeliac?

A

HLA-DQ2

HLA-DQ8

40
Q

What are the auto antibodies in coeliac?

A

anti TTG
anti EMA

Deaminated gliadin peptides antibodies

Important to test total immunoglobulin A levels, if total IgA is low coeliac test will be negative even when they have the condition
Can then test for IgG version

41
Q

How is coeliac diagnosed?

A

Remain on gluten diet
Check total immunoglobulin A to exclude IgA deficiency

Raised anti-TTG antibodies
Raised anti-endomysial

Crypt hypertrophy and villous atrophy on biopsy

42
Q

What conditions is coeliac disease associated with?

A 
Type 1 diabetes
Thyroid disease
Autoimmune hepatitis
Primary biliary cirrhosis
Primary sclerosing cholangitis
Down's
43
Q

What are the complications of untreated coeliac disease?

A 
Vitamin deficiency
Anaemia
Osteoporosis
Ulcerative jejunitis
Enteropathy associated T cell lymphoma of intestine
Non-Hodgkin lymphoma
Small bowel adenocarcinoma
44
Q

What are the features of Crohn’s?

A 
No blood or mucus
Entire GI tract
Skip lesions
Terminal ileum most affected
Transmural - full thickness inflammation
Smoking is a risk factor

Also associated with weight loss, strictures, fistulas

45
Q

What are the features of ulcerative colitis?

A 
Continuous inflammation
Limited to colon, rectum
Only superficial mucosa
Smoking is protective
Excrete blood and mucus
Use aminosalicylates
Primary sclerosis cholangitis
46
Q

What is the presentation of Crohn’s in children?

A

Growth failure
Puberty delayed

Abdominal pain, diarrhoea, weight loss

General ill health - fever, lethargy, weight loss

47
Q

What are the extra-intestinal manifestations of Crohn’s in children?

A 
Oral lesions
Perianal skin tags
Uveitis
Arthralgia
Erythema nodosum
48
Q

What investigations are helpful in confirming Crohn’s or diagnosing a relapse?

A

Raised inflammatory markers - platelet count, ESR, CRP
Iron deficiency anaemia
Low serum albumin

49
Q

What is seen on endoscopy in Crohn’s?

A

Hallmark is presence of non-caseating epithelioid cell granulomata

Small bowel imaging may reveal narrowing, fissuring, mucosal irregularitis
Bowel wall thickening

50
Q

How is remission in Crohn’s induced?

A

Steroids - oral prednisolone or IV hydrocortisone

Second line - azathioprine, mercaptopurine, methotrexate, infliximab

51
Q

How is remission maintained in Crohn’s?

A

First line - azathioprine, mercaptopurine

Or methotrexate, infliximab, adalimumab

52
Q

When is surgery required in Crohn’s?

A

If affecting distal ileum, can surgically resect to prevent further flares

Treat strictures and fistulas

53
Q

What is used to induce remission in ulcerative colitis?

A

Mild/mod disease - aminosalicylate e.g. mesalazine, or corticosteroids

If severe -
IV corticosteroids first line
or IV ciclosporin

54
Q

What is used to maintain remission in ulcerative colitis?

A

Aminosalicylate e.g. mesalazine oral or rectal
Azathioprine
Mercaptopurine

55
Q

When can surgery be offered in ulcerative colitis?

A

Panproctocolectomy will remove the disease

Left with ileostomy or oleo-anal anastomosis U pouch

56
Q

What is the presentation of ulcerative colitis in children?

A

Children often have pancolitis
Rectal bleeding, diarrhoea, colicky pain
Weight loss and growth failure less common

57
Q

What is seen on histology in ulcerative colitis?

A

Confluent colitis
Mucosal inflammation
Crypt damage - cryptitis, abscesses, crypt loss
Ulceration

58
Q

What are the clinical features of liver disease in children?

A 
Encephalopathy
Jaundice
Epistaxis
Cholestasis - pruritus, pale stools, dark urine
Ascites, hypotonia, neuropathy
Rickets
Varices, portal HTN
Spider naevi
Muscle wasting - malnourished
Splenomegaly
Liver palms, clubbing
59
Q

What are the causes of conjugated prolonged neonatal jaundice?

A

Bile duct obstruction - biliary atresia or choledochal cyst

Neonatal hepatitis syndrome

Intrahepatic biliary hypoplasia

60
Q

What are the causes of neonatal hepatitis syndrome?

A 
Congenital infection
Inborn errors of metabolism
A1 antitrypsin deficiency
Galactosaemia 
Tyrosinaemia
Errors of bile acid synthesis
Progressive familial intrahepatic cholestasis
CF
Intestinal failure associated liver disease
61
Q

What are the clinical features of viral hepatitis?

A 
Nausea
Vomiting
Abdominal pain
Lethargy
Most children don't develop jaundice
Large tender liver
30% have splenomegaly 
Liver transaminases elevated
62
Q

What are the types of viral hepatitis and their transmission?

A

Hep A - faecal oral, vaccination for travellers
Bed rest, change of diet

Hep B - 
Perinatal transmission
Infected blood
Needlestick injuries
Renal dialysis
Horizontal spread in families
(Sexual transmission)

Chronic infection by vertical transmission, can cause risk of cirrhosis or hepatocellular carcinoma
Interferon therapy

Hep C -
High in drug users, vertical transmission more common if also have HIV

D - co infection or super infection, E - water

63
Q

What are the causes of acute liver failure in children?

A

Fulminant hepatitis
Massive hepatic necrosis, loss of liver function with or without encephalopathy

Infection - viral hepatitis
Poisons/drugs - 
Paracetamol, isoniazid, phalloides mushrooms
Metabolic - Wilson's
Autoimmune hepatitis
Reye's syndrome
64
Q

What are the signs of acute liver failure?

A 
Jaundice
Encephalopathy
Coagulopathy
Hypoglycaemia
Electrolyte disturbances

Early signs of encephalopathy - alternate periods of irritability, confusion, drowsiness, aggression

65
Q

What are some of the complications of acute liver failure?

A

Cerebral oedema
Haemorrhage from gastritis or coagulopathy
Sepsis
Pancreatitis

66
Q

How can fulminant hepatitis be diagnosed?

A 
Transaminases very raised
Alkaline phosphatase increased
Coagulation very abnormal
EEG shows encephalopathy
CT may show cerebral oedema
67
Q

What is the management of acute liver failure?

A

Maintain blood glucose >4 with IV dextrose
Prevent sepsis; broad spectrum antibiotics and antifungals
Prevent haemorrhage, IV Vit K, FFP, cryoprecipitate, PPIs
Treat cerebral oedema by fluid restriction, mannitol
Urgent transfer to liver unit

68
Q

What features of acute liver failure suggest poor prognosis?

A

Shrinking liver
Rising bilirubin and falling transaminases
Worsening coagulopathy
Progression to coma

Without transplantation, 70% likely to die

69
Q

What is Reye syndrome?

A

Acute non inflammatory encephalopathy

Microvesicular fatty infiltration of liver

70
Q

What are the causes of chronic liver disease in children?

A 
Post viral Hep B, C
Autoimmune hepatitis
Drugs - nitrofurantoin, NSAIDs
IBD
PSC - +- ulcerative colitis
Wilson's
Alpha 1 antitrypsin def
CF
Neonatal liver disease
Bile duct lesions
71
Q

What is autoimmune hepatitis?

A

More common in girls
May present as acute hep, fulminant hep or CLD
Autoimmune features - rash, SLE, arthritis, haemolytic anaemia, nephritis

Respond to prednisolone, azathioprine

72
Q

What is Wilson’s disease?

A

Autosomal recessive
Reduced synthesis of caeruloplasmin and defective excretion of copper in bile
Leads to copper in liver, brain, kidney, cornea

Liver disease, neuropsychiatric features, extrapyramidal signs
Kayser Fleischer rings from age 7

Tx with penacillamine, promotes copper excretion, zinc to reduce absorption

73
Q

What occurs in cirrhosis?

A

End result of any liver disease, extensive fibrosis
May be asymptomatic if compensated, then:

palmar and plantar erythema
Spider naevi
Malnutrition, hypotonia

74
Q

What are the investigations for cirrhosis?

A

Screen for known cause of chronic liver disease
Upper GI endoscopy to detect varices, gastritis
Abdominal ultrasound
Liver biopsy

75
Q

What are some of the consequences of cirrhosis?

A 
Portal hypertension 
Splenomegaly
Oesophageal varices
Ascites - umbilical hernias
Spontaneous bacterial peritonitis - undiagnosed fever, pain, tenderness
Encephalopathy
Renal failure
76
Q

What are the indications for transplantation in chronic liver failure?

A

Sever malnutrition unresponsive to intensive nutritional therapy
Recurrent complications
Failure of growth and development
Poor quality of life

77
Q

What are some of the complications post liver transplantation?

A 
Primary non function of liver
Hepatic artery thrombosis
Biliary leaks, strictures
Rejection
Sepsis
78
Q

What is important in the management of children with liver disease?

A

Nutrition - high protein high carbohydrate, NG or TPN
Vit K, A, E, D

Pruritus - loose clothing, emollients, phenobarbital to stimulate bile flow, ursodeoxycholic acid

79
Q

What occurs in Vitamin A deficiency?

A

Night blindness in adults
Retinal changes in infants
Give oral supplements

80
Q

What occurs in Vitamin E deficiency?

A

Peripheral neuropathy
Haemolysis
Ataxia
High oral doses needed

81
Q

What occurs in Vitamin D deficiency?

A

Rickets
Pathological fractures
Vit D resistant rickets indicates renal tubular acidosis

Paediatrics (17 decks)

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