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Flashcards in Gastroenterology Deck (75):

Blood in vomit

Oesophagitis, peptic ulceration, oral/nasal bleeding


Projectile vomiting in first few weeks of life

Pyloric stenosis


Vomiting at the end of paroxysmal coughing

Whooping cough


Abdominal distension

Intestinal obstruction, including strangulated inguinal hernia


Blood in stool

Intussusception or gastroenteritis


Failure to thrive

GORD, coeliac disease and other chronic GIT conditions


What is posseting?

Is the return of small amounts of milk with the return of swallowed air - occurs in nearly all babies from time to time


What sort of infections can be associated with vomiting in infants

Gastroenteritis but also with UTI and CNS infections


When does GORD usually resolve by?

Usually resolves spontaneously by 12 months of age - due to maturation of lower oesophageal sphincter, assumption of upright posture and more solids in diet (liquid diet, lying down and immature sphincter are reasons for GORD)


Complications of GORD

Failure to thrive
Recurrent pulmonary aspiration
Dystonic neck posturing (sandifer syndrome)


Management of uncomplicated GORD

Adding inert thickening agents to feeds and positioning in head up 30degree position after feeding


Management of more severe GORD

Acid suppression with h2 receptor antagonists (ranitidine) or proton pump inhibitors (omeprazole)
Surgery if don't respond to medication or have oesophageal stricture


What is pyloric stenosis

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


Which infants is pyloric stenosis more common in

More common in boys 4:1
Particularly in first borns and may have a family history especially on maternal side


Type of vomiting in pyloric stenosis

Increases in frequency and forcefulness over time until it becomes projectile
Hunger after vomiting until dehydration causes loss of interest in eating


Diagnosis of pyloric stenosis

Feed test - gastric peralstasis wave moving across abdomen and pyloric mass (like olive) usually palpable in RUQ - ultrasound can be helpful


Management of pyloric stenosis

IV fluids to correct any fluid and electrolyte imbalance
Treatment by pyloromyotomy - Ramsteadt - division of muscle - quick recovery


Green vomit in child



What is colic?

Paroxysmal, inconsolable crying or screaming often accompanied by drawing up of the knees and passage of flatus several times a day - particularly in the evening


Incidence and period of colic

Occurs in first few weeks of life and resolved by 4 months of life and occurs in up to 40% of babies
Benign condition but can be worrying for parents


What can severe and persistent colic be due to?

Milk protein allergy or GORD


Causes of acute abdomen pain? x8

Appendicitis , hernia, hip joints and testes need to be checked
Lower lobe pneumonia
Primary peritonitis with nephrotic syndrome or liver disease
UTI and acute pyelonephritis


In what age is acute appendicitis uncommon in?

Uncommon in children under 3 years


Symptoms of acute appendicitis? x3

Vomiting (usually only a few times)
Abdominal pain, initially central and colicky and then localising to RIF


Signs in acute appendicitis?

Flushed face with oral fetor
Low grade fever
Abdominal pain aggravated by movement
Persistent tenderness with guarding in RIF


Why does diagnosis of acute appendicitis need to be made quickly in preschool children?

Perforation may be rapid - omentum is less developed


What might be identified in urine of acute appendicitis

White blood cells or organisms as inflamed appendix may be adjacent to ureter or bladder


What is intusseception?

Invagination of proximal bowel into a distal segment - most commonly the ileum passes into the caecum through the ileocaecal valve


At what age does intusseception commonly occur?

May occur at any age but peak age is between 3 months and 2 years


Most serious complication of intusseception

Constriction of mesentery therefore venous obstruction and engorgement, bleeding from mucosa, fluid loss and bowel necrosis


Presentation of intusseception

Paroxysmal, severe colicky pain and pallor - pale during pain - especially around mouth. May refuse feeds, may vomit
Sausage shaped mass palpable in abdomen
Abdominal distension and shock


Type of stool in intusseception

Characteristic red currant jelly stool comprising blood stained mucus - tends to occur later in illness
May be first seen on PR


Management of intusseception

Rectal air infusion normally enough (once child has been fluid resuscitated)
Ultrasound good to confirm diagnosis and see effect of treatment
Surgery if air infusion doesn't work


Cause of volvulus in infant

Malrotation of small bowel in fetal life, mesentery not fixed properly and predisposed to volvulus - causes obstruction


When does malrotation usually present

First 1-3 days of life from Ladd bands obstructing


What is abdominal migraine?

Migraine associated with abdominal pain - midline abdominal pain with vomiting and facial pallor
Usually family history of migraine


Possible causes of recurrent abdominal pain x2

Irritable bowel syndrome
Gastritis - including being caused by h.pylori (urea breath test)


Most common virus causing gastroenteritis in children

Rotavirus - now a successful vaccine been introduced


What sort of gastroenteritis is caused by E. coli and cholera?

Profuse, rapidly dehydrating diarrhoea


Which surgical disorders can mimic gastroenteritis x5

Pyloric stenosis, intusseception, appendicitis, necrotising enterocolitis, Hirschsprung disease


What systemic infections can mimic gastroenteritis

Septicaemia and meningitis


Which local infections can mimic pyloric stenosis

Respiratory tract infection, otitis media, hep A, UTI


Most serious complication of gastroenteritis

Dehydration leading to shock


Signs of dehydration

Weight loss (5-10% is clinical dehydration)
Depressed fontanelle
Pale or mottled skin
Reduced urine output
Cold extremities
Pli cutanee
Prolonged cap refill time
Dry mucous membranes
Sunken and tearless eyes
Tachycardia and weak peripheral pulses


What is hyponatraemic dehydration?

Normally with dehydration sodium and water loss is equal - but if fluid loss is replaced with water then sodium is less than water and causes shift of water from extra cellular to intracellular - increase brain volume causes convulsions

Also more shock


What is not useful in gastroenteritis

Anti diarrhoeal drugs because they prolong excretion of bacteria and are ineffective


Management of gastroenteritis without clinical dehydration ( >5% of body weight)

Prevent dehydration with good fluid intake and oral rehydration solution


Management of gastroenteritis if clinical dehydration but without shock

Oral rehydration solution
Continue normal fluid intake aka breastfeeding and give fluid deficit replacement over 4 hours (50ml/kg)
If dehydration continues consider IV fluids with 0.9% sodium chloride solution with 5% glucose - 50ml/kg if not shocked


Management of gastroenteritis if dehydrated and shocked

Fluid infusion
100ml/kg (10% of body weight)
0.9% sodium chloride solution with glucose


What should be avoided in dehydration with gastroenteritis

Fruit juices and carbonated drinks


What can sometimes occur after recovery from gastroenteritis

Temporary lactose intolerance with watery diarrhoea on returning to normal diet


Presentation of malabsorption x3

Abnormal stools (smelly and can't flush down toilet)
Failure to thrive
Nutrient deficiencies


Presentation of coeliac disease

Classical presentation is profound malabsorption syndrome at 8-24 months when wheat/gluten products are introduced - failure to thrive, abdominal distension, wasting of buttocks and abnormal stools
But now children present later in childhood - nonspecific gastrointestinal symptoms and anaemia (iron/folate deficiency) and growth failure


Tests for coeliac disease

IgA tissue transglutaminase antibodies and endomysial antibodies
Small intestine biopsy showing villus changes


What is toddler diarrhoea?

Non specific diarrhoea of varying consistency in preschool children
Thrive well
Probably due to maturational delay in bowel
Usually grow out by age 5
Diet needs a good amount of fat, not too much juice/squash and a normal about of fibre in diet


Crohn and UC from normal notes



Presentation of Crohn and UC in children

Crohn just generally unwell and failure to thrive but without gastrointestinal symptoms - can mimic anorexia nervosa
UC - rectal bleeding, diarrhoea and colicky pain - may also get failure to thrive but not as much as with crohns


What can long standing constipation in children cause

Can cause distension of rectum and then overflow involuntary soiling - need disimpaction regime with stool softeners etc and rectum will go back to normal after this
Must be followed by maintenance treatment
Fluid and fibre can help


General constipation in children

Children stool patterns vary as much as adults therefore parents reporting "constipation" is often not a problem


What is Hirschsprung disease?

Absence of ganglion cells from the myenteric and submucosal plexuses of part of large bowel causes a narrow constricted segment - extends from rectum, usually just affecting recto sigmoid colon - but can stretch further - causes obstruction and failure to pass meconium in first 24 hours of life


Signs of Hirschsprung

Abdominal distension and bile stained vomit
Failure to pass meconium
Rectal examination may reveal narrow segment
And removal of finger may lead to gush of liquid stool and flatus


How does Hirschsprung present in later childhood

Profound chronic constipation, abdominal distension and growth failure - usually without soiling


Diagnosis of Hirschsprung disease

Suction rectal biopsy - showing absence of ganglion cells, presence of large acetylcholinesterase positive nerve trunks


Management of Hirschsprung disease

Surgical - usually initial colostomy followed by anastomosing normal innervated bowel to anus


How make diagnosis of appendicitis

USS may help - but regular clinical review every few hours is best as appendicitis is a progressive condition
USS shows thickened, non-compressible appendix with increased blood flow


Management of appendicitis

If guarding already (perforation) then IV antibiotics and fluid resus before appendicetomy
If there is a mass palpable and no signs of peritonitis then can do IV antibiotics and conservative management - perform appendicetomy later on


Diagnosis of intussusception

Xray will show distended small bowel and absence of gas in the distal colon or rectum
Abdominal US may help confirm diagnosis and check response to treatment


Complication and urgent management of intussusception

Shock - therefore fluid resus is needed - due to pooling of fluid in the gut which may lead to hypovolaemic shock


Treatment of Crohns x3

Steroids and diet modification to induce remission
Immunosuppressants (azathioprine, mercaptopurine or methotrexate) to maintain remission
Anti-TNF (infliximab and adalimumab) if these fail


How does UC in children differ from it in adults?

90% have pancolitis as opposed to adults where it is normally confined to distal colon


Treatment of UC

Mild - aminosalicylates (balsalazide and mesalazine), more aggressive = systemic steroids for acute exacerbations and immunomodulatory therapy (azathioprine) to maintain remission


Leading cause of death in premature infants (bowel stuff)

Necrotising enterocolitis


Symptoms of necrotising enterocolitis (early and more advanced)

Early - feeding intolerance, abdominal distension and bloody stools
Quickly progress to abdominal discolouration, perforation and peritonitis


X ray signs in necrotising enterocolitis

Dilated bowel loops, bowel wall oedema, pneumatosis intestinalis (intramural gas) portal venous gas, air inside and outside bowel wall (Rigler sign), air outlining the falciform ligament (football sign)


Management of necrotising enterocolitis

IV fluids, TPN and IV antibiotics for 10-14 days to rest bowel