Gastroenterology

Question 1

How might a small bowel obstruction present in a neonate?

Answer 1

Persistant vomiting (will be bile stained unless site is above ampulla of vater)
Abdominal Distension becoming increasingly prominent
Meconium passage may be delayed or absent

Question 2

Why might the timing of presentation differ in a small bowel obstruction?

Answer 2

Higher lesions present soon after birth, but a lower lesion may not present for several days.

Question 3

List some of the causes of small intestine obstruction in neonates

Answer 3

Atresia or Stenosis of duodenum, jejenum or ileum
Malrotation with volvulus
Meconium Ileus
Meconium Plug

Question 4

What investigation would you do in a neonate with suspected small bowel obstruction?

Answer 4

Abdominal XR

Question 5

What is the management of small bowel obstruction in neonates?

Answer 5

Atresia and Malrotation are treated surgically
Meconium ileus treated with gastrograffin enema first
Meconium plugs often pass spontaneously

Question 6

List some of the causes of large bowel obstruction in neonates

Answer 6

Hirschsprung Disease

Rectal Atresia

Question 7

What is Hirschsprungs Disease and how does it present?

Answer 7

Absence of the myenteric nerve plexus in the rectum, which may extend along the colon
Baby initially will not pass meconium in the first 48hrs of life and the abdomen begins to distend.

Question 8

What is rectal atresia?

Answer 8

Absence of the anus at the normal site, lesions are high or low depending on whether the bowel ends above or below the levator ani muscle.
Management is surgical

Question 9

Describe soiling.

Answer 9

In long standing constipation the rectum becomes over distended, leads to a loss of feeling the need to defecate
Involuntary soiling may occur as contractions of the full rectum inhibit the internal anal sphincter, leading to overflow

Question 10

List some of the functional disorders associated with chronic abdominal pain in children

Answer 10

Functional Dyspepsia
IBS
Abdominal Migraine

Question 11

List some of the red flags that might make you think of an organic cause in a child presenting with recurrent abdominal pain?

Answer 11

diarrhoea, weight loss/weight faltering, blood in stools

vomiting, jaundice, bilious vomiting, abdominal distension, unexplained fever, Family Hx of IBD

Question 12

List some of the common viruses causing gastroenteritis.

Answer 12

Rotavirus
Adenovirus
Norovirus

Question 13

What questions are important to ask in a diarrhoea history?

Answer 13

Any contacts with people who have D&V
Recent travel abroad
Recent course of antibiotics
Food out of the ordinary
BLOOD? Indicates it might be a bacterial cause

Question 14

List some of the clinical signs of dehydration in children.

Answer 14

Dry Mucous Membranes
Reduced Skin Turgor
Prolonged Capillary Refill Time
Reduced Urine output
Sunken Eyes
Sunken Anterior Fontanelle
Rapid Pulse 
Body weight loss 
If severe - Drowsy

Question 15

What is different about UC in adults and children?

Answer 15

In adults the colitis is usually confined to the distal colon, in children 90% have pan-colitis

Question 16

How might Crohns disease present in children compared to adults?

Answer 16

In children - often lethargy and failure to thrive/weight loss is the main presenting feature. Only 25% get abdo pain and diarrhoea.

Question 17

How does Ulcerative Colitis tend to present in children?

Answer 17

Typically with rectal bleeding, diarrhoea and colicky pain

Question 18

When does coeliac disease classically present in children?

Answer 18

Usually between 8 and 24 months of age after the introduction of wheat containing weaning foods.

Question 19

How might a child with coeliac disease present?

Answer 19

Failure to thrive, abdominal distension, wasting of buttocks, abnormal stools and general irritability

Question 20

What happens to the small intestine in coeliac disease.

Answer 20

Gluten provokes damaging immunological response

Villi become progressively shorter and then absent, leaving a flat mucosa

Question 21

What is the gold standard for diagnosing coeliac disease?

Answer 21

Biopsy of small intestine

One while on gluten diet and one following resolution of symptoms following gluten withdrawal.

Question 22

Why is gastro-oeophgeal reflux so common in infancy?

Answer 22

Inappropriate relaxation of LOS due to functional immaturity
Predominantly fluid diet
Mainly horizontal posture
Short intraabdominal legnth of oeophagus

Question 23

When do gastro-oesophageal reflux symtpoms tend to resolve?

Answer 23

Nearly all spontaneously resolve by 12 months due to maturation of LOS, upright posture and more solids in diet.

Question 24

Lost some of the complications that may occur as a result of gastro-oesophgeal reflux in infancy.

Answer 24

Failure to thrive (rare)
Oesophagitis - haematemesis, heartburn - anaemia
Recurrent pulmonary aspiration - can cause recurrent pneumonia, cough or wheeze, apnoea

Question 25

What might be done to manage gastro-oesphgeal reflux of infancy?

Answer 25

Food thickeners and upright position after eating Medication - H2 receptor agonists or PPIs if has not resolved by 1 year Surgery - in those unresponsive to other things (Nissen Fundiplication)

Question 26

What is pyloric stenosis and when does it present?

Answer 26

Hypertrophy of the pyloric muscle causes gastric outlet obstruction Presents between 2-7 weeks of age

Question 27

How would a baby with pyloric stenosis present?

Answer 27

Vomiting - increasing in frequency and forcefulness over time - ultimately becoming projectile Hunger after vomiting until dehydration leads to loss in feeding Weight loss if presentation is delayed

Question 28

How do we diagnose pyloric stenosis?

Answer 28

Pyloric mass - feels like an olive, usually palpable in RUQ + visible peristalsis May be confirmed by ultrasound

Question 29

How is pyloric stenosis managed?

Answer 29

Correct fluid and electrolyte balance | Surgery

Question 30

What are the two ways cows milk protein intolerance can present?

Answer 30

IgE MEDIATED Occurs 10-15 minutes, usually after milk first ingested, if mild reaction may see uritcaria and facial swelling or if severe can have anapylaxis NON IgE MEDIATED Usually presents with diarrhoea and vomiting and failure to thrive. Colic or eczema may also be present.

Question 31

How might Tortion of Testes present?

Answer 31

There is typically sudden, severe pain in one testis. There may be lower abdominal pain and, in any boy presenting with abdominal pain, the testes should be checked May be nausea and vomiting May be history of previous self limiting episodes

Question 32

What is the management of testicular torsion?

Answer 32

Must be relieved surgically within 6-12 hours of the onset of symptoms for their to be a good chance of testicular viability If torsion is confirmed the collateral testes must be fixated because there may be anatomical predisposition to torsion If unsure SURGICAL EXPLORATION IS MANDATORY to rule out torsion

Question 33

What is the classical presentation of appendicitis?

Answer 33

Abdominal pain - initially vague and central, then localizing and severe in the RIF Nausea and Vomiting Anorexia

Question 34

How do we diagnose acute appendicitis?

Answer 34

It is a CLINICAL DIAGNOSIS based on symptoms If unsure can do bloods (WCC may be raised, alongside acute inflammatory markers) Ultrasound may help to confirm diagnosis, although appendix not always visualized CT is most sensitive and is being used more frequently.

Question 35

What is mesenteric adenitis?

Answer 35

Less severe, non-specific abdominal pain | Often accompanied by an URTI with cervical lymphadenopathy

Question 36

When can the diagnosis of mesenteric adenitis be made?

Answer 36

Can only definitively be made in those children where large mesenteric nodes are seen at laparotomy/laparoscopically and whose appendix is normal.

Question 37

Describe what happens in intussusception?

Answer 37

Telescoping of proximal bowel into a distal segment | Most commonly involves the ileum passing into the cecum through the ileocecal valve.

Question 38

When does intussusception typically present?

Answer 38

Betwen 3 months and 2 years, although may occur at any age | It is the commonest cause of intestinal obstruction in infants after the neonatal period

Question 39

How might an infant with intussusception typically present?

Answer 39

Paroxysmal severe colicky pain - during episodes of pain child becomes pale and draws up legs Becomes increasingly lethargic as time goes on May refuse feeds and may vomit which might be bile stained. Passing of characteristic redcurrant jelly stool - comprising blood stained mucus - occurs late. Eventually may have abdominal distension and shock

Question 40

What condition is redcurrant jelly stool classically associated with?

Answer 40

Intussusception

Question 41

What might you feel in the abdomen of a child with intussusception?

Answer 41

A sausage shaped mass

Question 42

How do we manage intussusception?

Answer 42

Unless signs of peritonism - reduction is attempted by the radiologist with rectal air insufflation - 75% success rate The remaining 25% require operative reduction

Question 43

What does dehydration look like on U&Es

Answer 43

Increased urea, small increase in creatinine