Gastroenterology Flashcards
(181 cards)
1
Q
medical causes of abdominal pain in children
A
- Constipation
- UTI
- Coeliac disease
- IBD
- IBS
- Mesenteric adenitis
- Abdominal migraine
- Pyelonephritis
- Henoch-Schonlein purpura
- Tonsilitis
- DKA
- Infant colic
2
Q
causes of abdominal pain in adolescent girls
A
- Dysmenorrhoea
- Mittelschmerz
- Ectopic preg
- PID
- Ovarian torsion
- Pregnancy
3
Q
surgical causes of abdominal pain in children
A
- Appendicitis
- Intussusception- colicky non specific abdo pain w/ redcurrent jelly stools
- Bowel obstruction
- Testicular torsion
4
Q
what are some red flags for abdo pain in children
A
- Persistent or bilious vomit
- Severe chronic diarrhoea
- Fever
- Rectal bleeding
- Weight loss or faltering growth
- Dysphagia
- Nighttime pain
- Abdominal tenderness
5
Q
what initial investigations may be done for abdominal pain in children and why?
A
- Anaemia can indicate IBD or coeliac disease
- Raised inflammatory markers can indicate IBD
- Raised anti-TTG or anti- EMA antibodies can indicate coeliac
- Raised faecal calprotectin IBD
- Positive urine dip - UTI
6
Q
what is recurrent abdo pain in children?
A
Repeated episodes of abdominal pain without identifiable cause. Non-organic or Functional. Common and can lead to psychological problems, such as missed days at school and parental anxiety. Overlap between diagnoses recurrent abdo pain, abdominal pain, IBS and functional abdominal pain.
Recurrent abdominal pain often responds to stressful life events, such as loss of a relative and bullying. Lead theory= increased sensitivity and inappropriate pain signals from visceral nerves.
7
Q
how is recurrent abdominal pain managed in children?
A
Management= Careful explanation and reassurance. To help:
- Distracting child from pain with other activities and interests
- Encourage pt not to ask about or focus on the pain
- Advice about sleep, reg meals, healthy balanced diet, staying hydrated, exercise and reducing stress
- Probiotic substances may help IBS
- Avoid NSAIDs
- Address psychological triggers and exacerbating factors
- Support from a school counsellor or child psychologist
8
Q
what are abdominal migraines?
A
episodes of central abdominal pain lasting >1 hour
occur in children before they develop traditional migraines as they get older
9
Q
what are some features of abdominal migraines?
A
- Central abdominal pain lasting >1 hour
- N&V
- Anorexia
- Pallor
- Headache
- Photophobia
- Aura
10
Q
how are abdominal migraines managed?
A
- Low stimulus environment- quiet dark room
- Paracetamol
- Ibuprofen
- Sumatriptan
11
Q
what preventative measures for abdominal migraines can be used?
A
- Pizotifen- serotonin agonist- withdraw slowly as associated withdrawal symptoms- depression, anxiety, poor sleep, tremor
- Propanalol
- Cyproheptadine- antihistamine
- Flunarazine- CCB
12
Q
what is idiopathic/functional constipation?
A
no significant underlying cause other than lifestyle factors
13
Q
name 3 important secondary causes of constipation in children?
A
Hirschsprung’s disease
CF
hypothyroidism
14
Q
how does constipation present in children?
A
- <3 stools per week
- Hard stools that are difficult to pass
- Rabbit dropping stools
- Straining and painful passing of stools
- Abdominal pain
- Holding an abnormal posture, referred to as retentive posturing
- Rectal bleeding associated with hard stools
- Faecal impaction causing overflow soiling, with incontinence of particularly loose smelly stools
- Hard stools may be palpable
- Loss of sensation of the need to open bowels
15
Q
what is encopresis?
A
Term for faecal incontinence. Not considered pathological until 4 years of age. Usually, a sign of chronic constipation where the rectum becomes stretched and loses sensation. Large stools remain in the rectum and only loose stools able to bypass the blockage and leak out, causing soiling.
16
Q
what are some lifestyle factors that impact constipation in children?
A
- habitually not opening the bowels
- low fibre diet
- poor fluid intake and dehydration
- sedentary lifestyle
- psychosocial problems such as a difficult home or school environment (keep safeguarding in mind)
17
Q
describe desensitisation of the rectum
A
Habit of not opening bowels when they need to and ignoring the sensation of a full rectum= lose sensation overtime and open less frequently faecal impaction rectum stretches and desensitised= more difficult to treat and reverse problem
18
Q
what are some secondary causes other than Hirschsprungs, CF and hypothyroidism?
A
- Spinal cord lesions
- Sexual abuse
- Intestinal obstruction
- Anal stenosis
- Cows milk intolerance
19
Q
what are some red flags for constipation?
A
no meconium w/in 48H birth (CF or Hirschsprung’s)
Neurological (cerebral palsy or spinal cord lesion)
Vomiting
ribbon stool
abnormal anus
abnormal lower back or buttocks
failure to thrive
Acute severe abdo pain and bloating
20
Q
complications of constipation
A
- Pain
- Reduced sensation
- Anal fissures
- Haemorrhoids
- Overflow and soiling
- Psychosocial morbidity
21
Q
how is constipation managed?
A
diagnosis of idiopathic constipation can be made without investigations, provided red flags are considered.
important to provide adequate explanation of the diagnosis and management as well as reassure parents about the absence of concerning underlying causes.
Explain that treating constipation can be a prolonged process, potentially lasting months.
- Correct any reversible contributing factors, recommend high fibre+ good hydrate
- Start laxatives (Movicol)
- Impaction= disimpaction regimen with high doses laxatives at first
- Encourage and praise visiting the toilet. This could involve scheduling visits, bowel diary and star charts.
Slow ween off as child develops a normal- regular bowel habit.
22
Q
what are the 4 types of laxatives and name examples of each
A
stool softeners
stimulant laxatives
bulk forming agents
osmotic laxatives
23
Q
what is GOR?
A
gastro oesophageal reflux
immaturity of the lower oesophageal sphincter
allows contents to easily reflux into oesophagus. Normal for baby to reflux feeds and provided there is normal growth, and the baby is otherwise well, there is no problem. Usually improves and 90% of infants stop having reflux by 1 year.
24
Q
how does GOR present?
A
normal to have reflux with large feeds
problem when is causes them to be distressed
- Chronic cough
- Hoarse cry
- Distress, crying or unsettles after feeding
- Reluctance to feed
- Pneumonia
- Poor weight gain
25
what are some other causes fo vomiting in children?
* Overfeeding
* GORD
* pyloric stenosis (projectile vomit)
* gastritis or gastroenteresis
* appendicitis
* infection- UTI, tonsillitis or meningitis
* Intestinal obstruction
* Bulimia
26
what are some red flags for vomiting in children?
* not keeping down any feed
* projectile or forceful vomiting
* bile stained, haematemesis or melaena
* abdominal distension
* reduced consciousness
* bulging fontanelle or neuro signs (meningitis or raised ICP)
* respiratory symptoms
* blood in stools (gastroenteritis or cows milk protein allergy)
* signs infection, rash/angioedema- sign allergy
* Apnoea
27
how is GOR managed?
* small frequent meals
* burping to help settle milk
* not over-feeding
* keep baby upright when feeding
* more problematic:
* gaviscon mixed with feeds
* thickened milk/formula
* Ranitidine
* Omeprazole where ranitidine inadequate
rare severe cases - barium meal and endoscopy
surgical fundoplication can be considered in v severe cases but rarely done
28
what is Sandifer's syndrome?
RARE condition causing brief episodes of abnormal movements associated w/ GORD in infants. Usually neurologically normal.
**_Features:_**
* **Torticollis**- forceful contraction of the neck muscles when twisting the neck
* **Dystonia**- abnormal muscle contractions causing twisting movements, arching of the back and unusual postures.
Tends to resolve as the reflux is treated or improves. Generally, the outcome is good.
refer to specialist for assessment as DDx include infantile spasms aka west syndrome and seizures
29
what is pyloric stenosis?
pyloric sphincter is ring of smooth muscle that forms canal between stomach and duodenum
it can hypertrophy and become narrowed = stenosis
powerful peristalsis to push feed into duodenum but cant pass through stenosis so peristalsis causes projectile vomiting
30
what are some features of pyloric stenosis
* Thin
* Pale
* Failing to thrive
* Projectile vomiting
31
what can be seen on examination of a baby with pyloric stenosis?
after feeding - peristalsis can be seen by observing the abdomen
firm round mass can be felt in upper abdomen
32
what ABG finding will be present in pyloric stenosis?
hypochloric hypokalemic metabolic alkalosis due to vomiting HCL
33
how is pyloric stenosis diagnosed?
abdominal uss to visualise thickened pyloric sphincter
34
how is pyloric stenosis managed?
laparoscopic pyloromyotomy - Ramstedts's operation
inscision made through the SM of the pylorus to widen canal allowing for food to pass from stomach to duodenum as normal
prognosis is good
baby cab feed after 6 h
35
what is coeliac disease?
autoimmune condition where exposure to gluten causes an immune reaction that creates inflammation in small intestine
Usually develops in early childhood but can start any age.
36
what are the 2 main antibodies involved?
anti-tissue transglutaminase (anti- TTG) and anti-endomysial (anti-EMA)
they correlate to disease activity and may disappear with effective treatment
37
what is the pathophysiology of coeliac disease?
Inflam SI especially the jejunum. Causes atrophy intestinal villi. Inflam- malabsorption of nutrients and disease related symptoms.
38
how does coeliac present?
Often asymptomatic
* Failure to thrive in young children
* Diarrhoea
* Fatigue
* Weight loss
* Mouth ulcers
* Anaemia secondary to iron, B12 or folate deficiency
* Dermatitis herpetiformis is an itchy blistering skin rash that typically appears on the abdomen
Rarely can present w/ neurological symptoms:
* Peripheral neuropathy
* Cerebellar ataxia
* Epilepsy
39
patients newly diagnosed with what condition are also tested for ceoliac and why?
type 1 DM as heavily linked
40
what are some genetic associations with coeliac?
HLA - DQ2 gene
HLA - DQ8 gene
41
what antibodies are involved? and what is the significance of IgA abs?
* Tissue transglutaminase antibodies (anti-TTG)
* Endomysial antibodies (EMAs)
* Deaminated gliadin peptides antibodies (anti-DGPs)
Anti-TTG and anti-EMA antibodies are IgA. Some patients have an IgA deficiency. When you test for these antibodies, it is important to test for total Immunoglobulin A levels because if total IgA is low the coeliac test will be negative even when they have the condition. In this circumstance you can test for the IgG version of the anti-TTG or anti-EMA antibodies or do an endoscopy with biopsies.
42
how is coeliac disease diagnosed?
investigatiosn must be carried out whilst person is still eating gluten
check total IgA levels to exclude IgA deficiency before checking coeliac disease specific antibodies
endoscopy and intestinal biopsy will show crypt hypertrophy and villous atrophy
43
what conditions are associated with coeliac disease?
* Type 1 diabetes
* Thyroid disease
* Autoimmune hepatitis
* Primary biliary cirrhosis
* Primary sclerosing cholangitis
* Down’s syndrome
44
what are some complications of untreated coeliac disease?
* Vitamin deficiency
* Anaemia
* Osteoporosis
* Ulcerative jejunitis
* Enteropathy-associated T-cell lymphoma (EATL) of the intestine
* Non-Hodgkin lymphoma (NHL)
* Small bowel adenocarcinoma (rare)
45
how is coeliac disease managed?
Lifelong gluten free diet essentially curative. Checking antibodies can be helpful in monitoring disease
46
what is biliary atresia?
Congenital condition where a section of the bile duct is either narrowed or absent. Results in cholestasis. Conjugated bilirubin is excreted in bile and therefore biliary atresia stops this.
Presents shortly after birth.
47
how does biliary atresia present?
* Shortly after birth
* Sig jaundice due to **high conjugated bilirubin levels -** liver is processing but cant be excreted
* Persistent jaundice \>14 days in term babies and 21days in premature babies
48
what investigations are done for ? biliary atresia?
Conjugated and unconjugated bilirubin.
high proportion of conjugated bilirubin suggests that the liver is processing it but it is unable to be excreted
49
how is biliary
Surgery- Kasai portoenterostomy involves attaching a section of small intestine to the opening of the liver, where the bile duct normally attaches. This is somewhat successful and can clear the jaundice and prolong survival. Often patients require a full liver transplant to resolve the condition.
50
what is intestinal obstruction?
blockage in the bowel
back pressure - vomiting and absolute constipation
51
causes of intestinal obstruction?
meconium ileus
Hirschsprung’s disease
Oesophageal atresia
Duodenal atresia
intussusception
imperforate anus
malrotation of intestines= volvulus
Strangulated hernia
52
how does intestinal obstruction present?
* Persistent vomiting, may be bilious containing bright green bile
* Abdo pain and distension
* Failure to pass stools or wind
* Abnormal bowel sounds. Can be high pitched and tinkling early in obstruction but absent later
53
how is intestinal obstruction diagnosed?
AXR may show dilated loops of bowel proximal to obstruction and absence of air in the rectum
(fluid level= Hirchsprungs and none= Meconium ileus)
54
how is intestinal obstruction managed?
* paediatric surgical unit as an emergency
* them NBM and inserting NGT to help drain stomach and stop vomiting.
* Also require IVF to correct electrolyte imbalance and keep them hydrated
55
what is hirschsprungs disease?
Congenital condition where the nerve cells of the myenteric plexus are absent in the distil bowel and rectum. Myenteric plexus aka Auerbach’s plexus forms enteric nervous system, brain of the gut. Responsible for peristalsis of large bowel (circular muscle layer).
56
pathophys of hirchsprung's disease?
**absence of parasympathetic ganglion cells** as in embryology these cells start higher up in GI tract and migrate down and if don’t travel all the way down, then part of the bowel left without any parasympathetic ganglion cells = Hirschsprung’s.
Length of colon without innervation varies:
* When entire= total colonic aganglionosis.
* Part w/o innervation= does not relax and becomes constricted= obstruction
Submucosa- Meissner’s plexus- secretion and blood flow
57
what are some genetic associations of hirschsprungs disease
family hx
downs syndrome
neurofibromatosis
Waardenburg Syndrome
multiple endocrine neoplasia type II
58
how does hirschsprung's disease present?
Severity of presentation and the age at diagnosis varies significantly depending on individual and amount of bowel affected. Acute intestinal obstruction after birth or gradual
* \>24H delay in passing meconium
* Chronic constipation since birth
* Abdo pain and distention
* Vomiting
* Poor weight gain and failure to survive
59
what is hirschsprung-associated enterocolitis?
Inflam and obstruction of intestine occurring in around 20% neonates with the disease.
Typically presents w/in 2-4 weeks of birth w/ fever, abdo distension, diarrhoea (often w/ blood) and features of sepsis.
Life threatening and can lead to toxic megacolon and perforation of the bowel.
Requires ABX, fluid resuscitation and decompression of obstructed bowel.
60
how is hirschsprungs investigated?
AXR can be helpful in diagnosing intestinal obstruction and demonstrating features HAEC
Rectal biopsy is used to confirm the diagnosis.
Bowel histology = absence of ganglionic cells.
61
how is hirschsprung's disease managed?
unwell and those with enterocolitis - IVF and management like obstruction
definitive management is by surgical removal of aganglionic section of bowel.
Most live normal life after corrective surgery, although they can have long term disturbances in bowel function and may be left with some degree of incontinence.
62
what is intersussception?
condition where the bowel “invaginates” or “telescopes” into itself
Thickens bowel and narrows lumen, leading to a palpable mass in the abdomen and obstruction to the passage of faeces through the bowel.
Typically occurs in infants 6 months to 2 years and is more common in boys.
63
what are some associated conditions with intussusception?
* Concurrent viral illness
* Henoch- Schonlein purpura
* CF
* Intestinal polyps
* Meckel diverticulum
64
how does intussusception present?
* Severe colicky abdominal pain
* Pale, lethargic, and unwell child
* Redcurrant jelly stool
* RUQ mass on palpation- sausage shaped
* Vomiting
* Intestinal obstruction
65
what is the initial investigation of choice for intussusception?
USS or contrast enema
66
how is intussusception managed?
Therapeutic enemas can be used to try and reduce intussusception.
Contrast, water or air are pumped into the colon to force the folded bowel out of the bowel into a normal position.
Surgical reduction may be necessary if enemas don’t work
If gangrenous or perforated surgical resection is required
67
what are some complications of intussusception?
* Gangrenous Bowel
* Obstruction
* Perforation
* Death
68
what is appendicitis?
Appendix is a small, this tube sprouting from the caecum. Becomes inflamed due to infection trapped in the appendix by obstruction at the point where the appendix meets the bowel. Inflammation can quickly proceed to gangrene and rupture. The appendix can rupture and release faecal content and infective material = peritonitis.
Peak incidence 10-12y/o
69
what are the clinical features of appendicitis?
* Migratory abdominal pain from central to RIF- tenderness McBurney’s point (1/3rd distance ASIS to umbilicus.
* Loss appetite
* N&V
* Rovsing’s sign- palpation LIF causes pain RIF
* Guarding on abdominal palpation
* Rebound tenderness
* Percussion tenderness
Rebound tenderness and percussion tenderness are signs of peritonitis from a ruptured appendix.
70
how is appendicitis diagnosed?
Clinical presentation and raised inflammatory markers
USS F patients to exclude ovarian and gynaecological pathology
CT scan
Clinical presentation but -ve investigations= Diagnostic laparoscopy to visualise appendix
71
key ddx for appendicitis?
ectopic preg
ovarian cyst
meckles diverticulum
mesenteric adenitis
appendix mass
72
what is an appendix mass?
occurs when the omentum surrounds and sticks to the inflamed appendix, forming a mass in the right iliac fossa.
This is typically managed conservatively with supportive treatment and antibiotics, followed by appendicectomy once the acute condition has resolved.
73
how is appendicitis managed?
Emergency admission to hospital under surgical team.
Older children, \>10y/o can often be managed by adult teams provided there is a paediatric department in the hospital.
Younger= paed surgeons
Appendicectomy is definitive- laparoscopy or laparotomy
74
what are some complications of appendicectomy?
* Bleeding, infection, pain and scars
* Damage to bowel, bladder and other organs
* Removal of a normal appendix
* Anaesthetic risks
* VTE risk
75
what is hepatitis?
inflammation of the liver
76
what causes hepatitis?
alcoholic, NAFLD, autoimmune, drug induced ie paracetamol
77
how does hepatitis present?
* Abdominal Pain
* Fatigue
* Pruritis
* Muscle and joint aches
* N&V
* Jaundice
* Fever (VIRAL)
* Hepatic picture LFT
78
what is the typical biochemical findings for hepatitis?
LFT deranged
high transaminases with proportionally less of a rise in ALP = hepatic picture
79
what is hepatitis A?
most common viral hepatitis in world - rare in UK
RNA virus transmitted via faecal=oral route by contaminated water/faeces
presents with nausea, vomiting, anorexia & jaundice
can cause cholestasis = dark urine and pale stools, moderate hepatomegaly
resolves without treatment in 1-3 months
basic analgesia
vaccination
notifiable disease
80
what is hepatitis B?
DNA virus transmitted by direct contact with blood or bodily fluids - sex, sharing household products, contact between cuts/abrasions
also vertical transmission
fully recover within 2 months - 10% become chronic hep b carriers - will cont. to produce viral proteins
81
hepatitis B antibodies
* Surface antigen (HBsAg) – active infection
* E antigen (HBeAg) – marker of viral replication and implies high infectivity
* Core antibodies (HBcAb) – implies past or current infection
* Surface antibody (HBsAb) – implies vaccination or past or current infection
* Hepatitis B virus DNA (HBV DNA) – this is a direct count of the viral load
82
vaccination for Hep B
Part of the 6 in 1 vaccine
83
how is hep b managed?
* Low threshold to screen
* Screen BBV- A, B, HIV and STI
* Refer gastro, hepatology or ID and PHE
* Stop smoke and alcohol
* Education about reducing transmission and informing potential risk contacts
* Test Complications- Fibroscan for cirrhosis and USS for hepatocellular carcinoma
* Antiviral medication can be used to slow progression of the disease and reduce infectivity
* Liver transplant in end stage disease.
84
what is hepatitis C?
RNA virus. Spread by blood and bodily fluids. No vaccine available and now curable by direct antiviral medications.
COURSE
* 1in4 fights off and makes full recovery
* 3in4 becomes chronic
* Complications- Liver cirrhosis and associated complications and hepatocellular carcinoma
Testing- HepCab and HepC RNA to calculate viral load and assess for individual genotype
85
how is hepatitis c managed?
* Same as B
* Direct acting antiviral tailored to specific genotype. Successful in 90% and taken 8-12 weeks
* Transplant end stage
86
what is hepatitis D?
RNA virus- only pt with HepB as attaches itself HBsAG. Very low rates UK. No treat and notify PHE
87
what is hepatitis E?
RNA virus transmitted faecal oral. VERY RARE. Mild illness, no treatment required. Rarely chronic and liver fail and more so in immunocomp. Notifiable PHE. No vaccination.
88
what is autoimmune hepatitis?
Chronic hepatitis not sure exact cause however could be some genetic predisposition and triggered environmental, such as viral infection = T cell- mediated response against liver cells.
Type 1:adults
Type 2: occurs children
Type 1 typically affects women in their late forties or fifties. It presents around or after the menopause with fatigue and features of liver disease on examination. It takes a less acute course than type 2.
In type 2, patients in their teenage or early twenties present with acute hepatitis with high transaminases and jaundice.
89
what investigations are done for autoimmune hepatitis?
Raised transaminases, IgG levels and it is associated with many autoantibodies.
T1 autoantibodies = ANA, Anti-smooth muscle ab (anti-actin), Anti-soluble liver antigen (anti- SLA/LP
T2 autoantibodies = Anti-liver kidney microsomes-1 (Anti-LKM1), Anti-liver cytosol antigen type 1 (anti-LC1)
Diagnosis can be confirmed in a liver biopsy
90
how is autoimmune hepatitis managed?
High dose prednisolone that are tapered over time as other immunosuppressants, particularly azathioprine are introduced.
Immunosuppressant treatment is usually successful in inducing remission however usually lifelong.
Liver transplant end stage although can recur
91
what are some symptoms of liver failure?
* Malaise
* Abdominal pain
* Nausea ± vomiting
* Weight loss
* Jaundice
92
what are some signs of liver failure?
* Bruising and bleeding – signs of coagulopathy
* Hypoglycaemia
* Oedema
* Loss of consciousness
* Irritability
* Drowsiness
93
ddx/causes for liver failure
* Infection – hepatitis, CMV, EBV, parvovirus B19, herpes simplex
* Drugs – paracetamol, anticonvulsants
* Autoimmune
* Metabolic – Wilson’s disease
* Ischaemia – congenital heart disease
* Malignancy – leukaemia
94
what investigations can be done for liver failure?
* Bloods – FBC, coagulation screen, G&S, U&Es, creatinine, LFTs, CRP
* Blood sugar levels
* Blood gas
* Lactate
* Ammonia
* Amylase
* EEG or CT if grade 2 encephalopathy or higher
* Abdominal USS
* CXR
* ECG
95
how is paediatric acute liver failure defined?
biochemical evidence of acute liver injury in a child, with no known evidence of chronic liver disease and at least 1 of the following:
* INR \>1.5 with encephalopathy
* INR \>2.0 without encephalopathy
96
how is liver failure managed?
* IV omeprazole
* IV vitamin K
* PO/NG lactulose- reduce ammonia in blood
* IV Cefazolin (B lactam ABX)
* Analgesia
* Avoid sedating medications
Indications for admission to ITU include:
* Grade 2 encephalopathy or higher
* Cardiovascular or respiratory instability
* Multiorgan failure
97
what is peptic ulcer disease?
ulceration of the mucosa of the stomach (gastric ulcer) or the duodenum (duodenal ulcer).
Duodenal ulcers are most common.
98
what is the pathophysiology of peptic ulcer disease?
protective layer in the stomach comprised of mucous and bicarbonate secreted by the stomach mucosa. This protective layer can be broken down by:
* Medications (e.g. steroids, NSAIDs)
* H. pylori
99
what are the clinical features of peptic ulcers?
* Epigastric discomfort/pain – eating worsens the pain of gastric ulcers, and improves the pain of duodenal ulcers
* Nausea ± vomiting
* Dyspepsia
* Haematemesis
* Iron deficiency anaemia
100
what are some ddx for peptic ulcer disease?
Crohn’s disease**,** Oesophagitis**,** Cholecystitis
101
how is peptic ulcer disease investigated?
* Endoscopy
* Rapid urease test – to check for H. pylori
* Stool tests
* Biopsy – exclude malignancy
102
how is peptic ulcer disease managed?
* High-dose PPI
* H. pylori eradication regime
103
complications of peptic ulcer disease?
* Haemorrhage
* Perforation – peritonitis
* Strictures
* Pyloric stenosis
104
what is gastritis?
inflammation or irritation of the lining of the stomach?
105
what are some causes of gastritis?
* Toxic object swallowed
* Trauma to the stomach
* NSAIDs
* DM
* Thyroid disease
* Crohn’s disease
106
what are the clinical features of gastritis in infants and young children?
* Vomiting
* Failure to thrive
* Weight loss
* Chronic diarrhoea
* Haematemesis
* Iron-deficiency anaemia
* Irritability
107
what are the clinical features of gastritis in children and adolescents?
* Abdominal pain
* Anorexia
* Nausea ± vomiting
* Heartburn
* Hematemesis
* Iron-deficiency anaemia
108
what investigations are done for gastritis?
bloods
stool test
urease breath test
endoscopy
109
how is gastritis managed?
* High-dose PPI Ranitidine before
* H. pylori eradication regime
110
what is h. pylori and how is it eradicated?
a gram -ve bacteria. Urease producing.
Eradication can be achieved with a 7-day course of:
* PPI + amoxicillin + clarithromycin/metronidazole
* PPI + metronidazole + clarithromycin (if penicillin allergic)
111
what is volvulus?
when the bowel and its mesentery twist around itself
## Footnote
Mesentery= membranous peritoneal tissue that creates a connection between the bowel and the posterior abdominal wall.
Closed-loop bowel obstruction.
Can cause ischaemia and bowel necrosis.
112
what are the different types of volvulus?
**Sigmoid** (older, bed bound, key cause= constipation= lengthen mesentery causing it to go down and twist, also associated with a high fibre diet and the excessive use of laxatives)
**Caecal**- less common and tends to affect younger patients. Twist occurs in the caecum.
113
risk factors for volvulus
neuropsych disorders (Parkinsons), Nursing home residents
chronic constipation
high fibre diet
pregnancy
Adhesions
114
how does volvulus present?
* Vomiting (particularly green bilious vomit)
* Abdominal distension
* Diffuse abdominal pain
* Absolute constipation and lack of flatulence
115
how is volvulus diagnosed?
Diagnosis= coffee bean sign in sigmoid volvulus
Contrast CT
116
how is volvulus managed?
NBM, NGT, IVF
Conservative management with endoscopic decompression can be attempted in pt with sigmoid volvulus.
Flexible sigmoidoscope is inserted carefully, with the patient in the left lateral position, resulting in correction of the volvulus. A flatus tube/rectal tube placed temporarily to help decompress the bowel and is later removed.
60% risk recurrence
Surgical:
* Laparotomy
* Hartmann’s
* Ileocecal resection or right Hemicolectomy for caecal volvulus
117
what is peritonitis?
Inflammation of the peritoneum and can have localised with inflammation of the underlying organ
## Footnote
M\>W, In women they can occur with rupture to reproductive organs
118
what are symptoms of peritonitis?
* Sudden onset acute abdominal pain exacerbated by movement
* Generalised but then become localised visceralparietal
* Shock and fever
* Washboard rigidity
* Fever
* Sinus tachycardia
* N&V
* Abdominal swelling
* Dullness may occur after 2-4H
119
what are some causes of peritonitis?
* Infected peritonitis- perf= gram -VE (E.Coli), surgery or trauma (staph aureus), SBP in children or those with ascites. Treated differently and normally only requiring abx, systemic infection=TB
* Non-infected= leakage of sterile bodily fluids into the peritoneum- bld bile, urine- sterile to start but then bacterial in 24-48H= full blown peritonitis
* Auto-immune disease- lupus can cause peritonitis
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how is peritonitis investigated?
erect CXR
serum amylase to rule out pancreatitis
USS/CT scan
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how is peritonitis managed?
IVF
IVABX if infective
Surgery= laparotomy- if normal urine output attained. Repair perf and washout. Antibiotic wash
Left untreated= fatal
Easily treated surgically= mortality\<10% and rise 40% in elderly
Later present= likely fatal consequences, particularly those after 48H
After surgery= IV feed
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what are some complications of peritonitis?
Loss fluids/electrolyte imbalance
Difficulty breathing
Peritoneal abscess
Septicaemia
Abscess
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what is duodenal atresia and stenosis?
**first part of the small bowel (the duodenum) has not developed properly**. It is not open and cannot allow the passage of stomach contents.
associated with HPB anomalies
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what are some clinical features of duodenal atresia?
* Intrauterine polyhydramnios
* Bilious vomiting- severe= few hours after birth
* Distended upper abdomen and scaphoid lower abdomen
* Delayed meconium
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how is duodenal atresia diagnosed?
* Prenatal USS- polyhydramnios, dilation of stomach and duodenum= double bubble sign
* Postnatal XR- double bubble, gasless distil bowel
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how is duodenal atresia managed?
Preoperative- PN via central catheter shortly after birth and fluids for electrolyte replacement and hydration.
Also Gastric decompression.
Surgical bypass of atresia or stenosis - Duodenoduodenostomy
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what is an omphalocele?
Ventral abdominal wall defect- congenital herniation of abdominal viscera through the abdominal wall at the umbilicus
Hernial sac covered in amniotic membrane and peritoneum
Impaired closure of the umbilical folds.
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what are some risk factors for omphalocele?
m\>f
trisomy 21, 18, 13
Beckwidth-Weidemann Syndrome
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what are the clinical features of omphalocele?
* premature infants
* Umbilical hernia sac- May contain liver, gall bladder, intestine
* Features of associated conditions
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how is omphalocele diagnosed?
clinical diagnosis at birth
prenatal uss - polyhydramnios and high maternal serum AFP
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how is omphalocele managed?
C-section to avoid rupture
Vaginal delivery possible if small
Wrap sac in sterile saline dressing covered with plastic wrap
NG suction
IVF to avoid abdo distension to compensate fluid loss
Surgery- prim closure or secondary (staged silo repair, skin graft or dermal patch)
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what are some complications of omphalocele?
Rupture hernial sac with infection-peritonitis
Secondary intestinal wall atresia as a result of injury
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What is gastroschisis?
Ventral wall defect that results in paraumbilical herniation of the intestine through the abdominal wall without formation of a hernia sac.
Failed formation of a large peritoneal cavity=rupture or fail return
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what are the clinical features of gastroschisis?
Protrusion of intestinal content usually on the right side of umbilicus
Not contained in a hernia sac and appears edematous, erythematous and dull
Shortened bowel
Malabsorption caused by mucosal damage
Peritonitis
Seen especially in premature infants and associated cryptorchidism and GI stenoses or atresia
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how is gastroschisis diagnosed?
Clinical diagnosis
Can be detected prenatally like omphalocele
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how is gastroschisis managed?
C section no better than a vaginal delivery
Same as omphalocele
Emergency surgery- Prim abdo wall closure or staged silo repair
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what is a transoesophageal fistula?
congenital anomaly resulting in a tract between trachea and oesophagus
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what is transoesophageal fistula associated with?
VACTERL anomalies
vertebral, anal, cardiac, tracheal, oesophageal, renal, limb defects
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how does a transoesophageal fistula present?
Increased oral secretions- drooling
Feeding difficulty
Gagging/choking
Hyperventilation or other resp dysfunction
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what is seen on examination of transoesophageal fistula?
Resp distress
Polyhydramnios in utero
Rales on pulmonary auscultation
Cyanosis
Abdo distension- caused by swallowing air during feeding
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what imaging is done for transoesophageal fistula?
CXR- may show NG coiled oesophagus
KUB- Air GI tract
Bronchoscopy- confirms anatomical abnormality
Prenatal USS- polyhydramnios
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how is transoesophageal fistula managed?
Surgical= repair- emergency when identified as prevents further lung damage
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what are some complications of transoesophageal fistula
Aspiration pneumonia
Choking
Oesophageal stricture post op
Reflux post op
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what is meckel's diverticulum?
Congenital anomaly of the Gi tract and is caused by an incomplete obliteration of the omphalomesenteric duct.
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what is the rule of 2s for meckels diverticulum?
2 inches long
2 feet from the ileocaecal valve
2% pop
2:1 M:F
presents \<2yrs with painless lower GI bleeding.
2 types of mucosa - native ileal or ectopic (most common) could be gastric, pancreatic etc
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what are some clinical features?
Asymptomatic- most common and an incidental finding in abdominal surgery
**Symptomatic:**
* Lower GI bleeding= Haematochezia, Tarry stool, Currant Jelly stools
* Abdominal pain
* N&V
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what imaging is done for meckels diverticulum?
Lower GI bleed- \<10y/o, adults with no abnormalities on endoscopy, colonoscopy, CTscan
Meckel scintigraphy- non-invasive nuclear medicine technique, which is absorbed by the gastric mucosa and identify ectopic gastric mucosa
CT angio
OTHER- Mesenteric angiography, Tagged RBC scans
NEW= double balloon enterostomy to visualise entire small bowel.
Capsule endoscopy
Diagnostic laparoscopy
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how is meckels diverticulum managed?
**Asymp:**
* Children or young adults= resect
* Adult\<50= surgical resect high risk complications
* Adults\>50 no treatment necessary
**Symptomatic or complicated:**
* Initial stabilisation of the pt, Surgical resection of all symptomatic/complicated
* Procedures- segmental resection (indicated for bleeding, broad base or palpable abnormality) or diverticulectomy
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what are some complications of meckels diverticulum?
Haemorrhage
Bowel obstruction- intussusception, volvulus, Littre hernia: incarceration of Meckel diverticulum inside femoral hernia.
Bowel perf, peritonitis, intra-abdominal abscess
Infection
Neoplasia-rare- leiomysarcomas, carcinoid tumours, lipomas, fibromas, angiomas
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complications of malrotation?
volvulus
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what is a hiatus hernia?
Protrusion of a whole or part of an organ through the wall of the cavity that contains it into abnormal position. Extremely common, however exact prevalence hard to state. 1/3rd over 50 have a hiatus hernia.
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what are the 2 types of hiatus hernia?
* **Sliding Hiatus Hernia (80%)-** GOJ, the abdo part of the oesophagus, and freq the cardia of the stomach slides upwards through the diaphragmatic hiatus into thorax
* **Rolling or para-oesophageal**- upward movement of the gastric fundus occurs to lie alongside a normally positioned GOJ= create a bubble of the stomach. True hernia with peritoneal sac.
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what are some risk factors for hiatus hernia?
age - loss of diaphragmatic tone
pregnancy
obesity
ascites
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what are the clinical features of hiatus hernia?
Asymp
* Reflux
* Vomiting
* Weight loss
* Bleed or anaemia
* Hiccups or palpitations
* Swallowing difficulties
* Clinical exam normal
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what investigations are done for hiatus hernia?
OGD gold standard
Diagnosed incidentally CT or MRI
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what is the management of hiatus hernias?
Conservative- PPI, weight loss and alteration of diet (low fat, earlier meals, smaller portions)
Smoking cessation and reduction in alcohol intake should be advised, as both nicotine and alcohol are thought to inhibit LOS function, thereby worsening symptoms.
**Surgical Management**
Indicated when:
* Remaining symptomatic, despite max therapy
* Increased risk of strangulation/volvulus
* Nutritional failure (gastric outlet function)
Cruroplastly- hernia is reduced- large defects require mesh to strengthen repair
Fundoplication- Strengthen LOS and helping reflux and keep the GOJ in place below the diaphragm- wrap full or partial
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what are the complications of hiatus hernia?
Rolling= incarceration and strangulation
Gastric volvulus when twists on itself= obstruct gastric passage and tissue necrosis and requires prompt surgical intervention
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what is Borchardts triad - acute gastric volvulus?
severe epigastric pain
retching w/o vomiting
inability to pass NG tube
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what is an inguinal hernia?
Protrusion of a viscus through the wall of the cavity that contains it
* Direct=20%= Hesslebachs triangle- older and secondary to abdo wall laxity and increase abdo pressure.
* Indirect= 80%= Deep inguinal ring= incomplete closure processes vaginalis from vesicular descent- lat to epigastric vessels
Deep ring is transverse fascia. Superficial ring= external oblique
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what are some risk factors for hernia?
male
increased age
increased abdo pressure
obesity
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clinical features of inguinal hernia?
* Lump in the groin
* Mild/mod discomfort when activity or stand
* Incarcerated=pain, tender, erythematous
* Bowel ob= if reducible, V painful out clinical picture= strangulated-X blood= tense tender lump
* Cough impulse- irreducible= no
* Location= inguinal superomedial to pubic tubercule. Femoral inferolateral to pubic tubercule
* Reducible = on lying down +/- minimal pressure
* Testes above, separate?
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how is inguinal hernia investigated?
* Imaging if not sure
* USS-CT
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how is an inguinal hernia managed?
risk strangulate 3%
* Strangulated- urgent surgical intervention
* No symptoms= conservative- safety net and likely surgery future
* Symptomatic= surgery after
**Surgery**
Open repair (++ cost effective prim inguinal)- Lichentein technique or laparoscopic total extra peritoneal (TEP) or transabdo pre-peritoneal TAP
URGENT= incarcerated, obstruct, strangulate
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what are some complications of inguinal hernia?
Pain, bruise, haematoma
Recurrence
Chronic pain
Damage vas or test vessels- ischaemic orchitis or test vessels
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why are femoral hernias higher risk for strangulation?
narrow femoral canal and ring
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what are the clinical features of femoral hernia?
* Small lump groin= only or strangulation
* How exactly location
* Unlikely reducible
* Older F+ vom= examine groin
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what investigations are done for femoral hernias?
uss
CT abdo pelvis
all for surgical intervention
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how are femoral hernias managed?
* Low approach= incision below inguinal ligament= not interfering inguinal structures but limit space removal small bowel
* High approach= above inguinal lig= preferred emergency= easy access compromised small bowel
* Reduce+narrow femoral ring w/ sutures medially between the pectineal and inguinal ligaments or mesh plug
* Emergency= incarcerated, obstructed, strangulated
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what is mesenteric adenitis?
an important cause of right iliac fossa pain in children, and as such is important as a differential diagnosis of appendicitis.
due to non- specific inflammation of the mesenteric lymph nodes which provokes a mild peritoneal reaction and stimulates painful peristalsis in the terminal ileum.
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what causes mesenteric adenitis?
infection - usually viral
common in under 16
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what are the symptoms of mesenteric adenitis?
* Sore throat or symptoms of a cold before the tummy pain started
* Pain in the tummy. Pain is usually in the middle of the abdomen. May be RIF pain
* Fever
* Nausea and/or diarrhoea
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how is mesenteric adenitis diagnosed?
exclude other causes ie appendicitis
* Wait and see, with another check by your doctor a few hours later to see if symptoms have changed
* Second opinion- eg, a referral for surgical opinion
* Tests to look for other conditions
* Blds, Urine dip, USS or CT.
* May need laparoscopy
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how is mesenteric adenitis managed?
Analgesia if required
Bacterial infection= need abx
RED FLAG Safety netting
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what is gastroenteritis?
Gastroenteritis is inflammation all the way from the stomach to the intestines and presents with nausea, vomiting and diarrhoea
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what is the most common cause of gastroenteritis?
viral
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what is the main concern with patients with gastroenteritis?
dehydration - need to establish whether they can keep themselves hydrated or if they need IVF
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what are some conditions to think about when a child presents with loose stools?
* Infection (gastroenteritis)
* Inflammatory bowel disease
* Lactose intolerance
* Coeliac disease
* Cystic fibrosis
* Toddler’s diarrhoea
* Irritable bowel syndrome
* Medications (e.g. antibiotics)
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what are the 2 most common viral gastroenteritis?
rotavirus
norovirus
(adenovirus is less common and more subacute diarrhoea)
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describe the different causes of gastroenteritis
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how is gastroenteritis managed?
good hygiene
barrier nurse
stay off school 48 hours after symptoms have completely resolved
microscopy, culture and sensitivities to establish cause and need for abx
ensure hydration - fluid challenge, rehydration sachets
dehydrated or those who fail fluid challenge may need IVF
once oral intake is tolerated light diet can be started - toast is good to start
antidiarrhoeal and antiemetic medication are avoided
abx for those at high risk
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what are some long term complications of gastroenteritis?
* Lactose intolerance
* Irritable bowel syndrome
* Reactive arthritis
* Guillain–Barré syndrome
