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Flashcards in Gastroenterology Deck (39):
1

Definition of Failure to Thrive (FTT) and nutrition

FTT - suboptimal wght gain in infants and toddles AKA faltering growth/weight

Nutrition -  intake of food, considered in relation to the body's dietary needs.

2

NICE guidelines on infant feeding (abridged)

Breast feeding

  • Ensure good attachement and positioning
  • Look for baby and mum indicators of successfull feeding e.g. audible swallow + breast feel empty
  • Know how to pump and store milk
  • Know signs to look out for related to breast feeding issues e.g. nipple pain

Bottle feeding

  • Ensure mum knows associated risks
  • Ensure mum knows how to give and make formula
  • Get advice from independant source not advertising

General advice

  • Good indicators for child health: colour, temp, regular UO, regular stools
  • Babies should: initiate feeds, suck well and settle between feeds
  • They should not be excessively irritable, tense, sleepy or floppy
  • Vital signs: 30-60 RR, 100-160 HR, 37 deg in normal room

3

Where to find advice on breast feeding

Midwife

NICE postnatal care (bit hard for gen pop)

NHS breast feeding page

4

Types of formula and their indications

All based on varying levels of modified cows milk

Whole protein - Standard formula

Semi-hydrolysed - Based on modified cows milk and 100% whey protein. Marketed as easier to digest. In studies no difference found.

Hydrolysed - Supposed to be for cows milk allergies. 

 

(NICE) considers that there is insufficient evidence to suggest that infant formulas based on partially or extensively hydrolysed cows’ milk protein can help prevent allergies (National Institute for Health and Clinical Excellence, 2008)

 

this is a very extensive document: http://www.firststepsnutrition.org/pdfs/draft_specialised_milks_mar_2013.pdf 

 

5

Key Hx taking points in FTT or faltering growth

  • Dietary Hx, incl food diary of several days
  • Feeding, exactly what happens during meal times
  • Child well with lots of energy?
  • Other Sx: diarrhoea, vomiting, cough, lethargy
  • Prematurity?
  • IUGR?
  • Other significant medical issues
  • FHx of growth +/- illnesses
  • Development normal?
  • Psychosocial problems at home?

6

Differentials for failure to thrive/faltering growth

Inadequate intake

Non-organic/Environmental

  • Inadequate food available e.g not enough of what they having, poor breast technique, lack of interest in feeding, not enough money
  • Psychosocial deprivation: e.g. maternal depression
  • Neglect of child abuse: deliberate underfeeding

Organic (only 5% of FTT)

  • Impaired suck/swallow e.g. neuro issues
  • Chronic illness anorexia: crohns 

Inadequate retention

  • Vomiting/GORD

Malabsorption

  • Coeliac, Cystic fibrosis, allergy

Failure to utilise nutrients

  • Downs, metabolic disorders

Increased requirement

  • Thyrotoxicosis, malignancy, chronic infection (HIV)

 

7

Importance of nutrition scoring 

Nutrition scores can do all sorts of things.

The one mentioned is MUST which tells you according to your wght now and 6 months ago and your health status what changes to make to your nutrition. http://www.bapen.org.uk/screening-and-must/must-calculator

There are loads of different ones for children,

  • STRONGKIDS best for quick assessment of all aged children
  • PYMS or STAMP are a bit longer but will detect all children with malnourishment and provide advice

8

Presenting features of kwashiorkor (protein malnutrtion)

  • Generalised odema
  • Sever wasting
  • Due to odema wght might not be too bad
  • Flaky paint skin w/ hyperkeratosis (thick skin) + desquamation
  • Distention
  • Hepatomegaly
  • Angular stomatitis
  • Sparse depigmented hair
  • Diarrhoea
  • Hypothermia
  • Bradycardia
  • Hypotension

9

S&S of overfeeding

  • Gaining too much wgt
  • >7 heavy wet nappies a day
  • Frequent sloppy foul smelling motions
  • Flatulence
  • Belching
  • Milk regurg
  • Irritability
  • Sleep disturbance

10

Approximate recommended intake for 0-3 mnts, 3-6 months and 6-12 months

0-3: 115 kcal/kg/day = 185 mls of breast milk/kg/day

 

3-6: 115 kcal/kg/day =  185 mls of breast milk/formula /kg/day

 

SOLID FOOD INTRODUCED AT 6 MONTHS

 

6-12: 95kcal/kg/day =  Two meals a day, each 2-4 tablespoons

11

Hx of constipation and how differentiate from Hirschprungs

Def  of constipation- Infrequent dry hardened faeces often w/ straining and pain. May wax and wane + be accompanied overflow soiling

Age - Hirschprungs usually presents in first 48 hours of life. More unlikely the older you get

Failure to pass meconium - Classic Hirschprungs, may have been delayed so ask

Bilious vomiting (green) -  This will be a later Sx in Hirschprungs defo not constipation.

Failure to thrive - Simple constipation should not present with this something else is going on. Not Hrisch specific

Frequency of bowels - In Hirsch you get profound constipation i.e. nothing passes for weeks. Infants should go 4 times a day in 1st week of life, this falls to 2 per day by 1st year. Breast fed infants may not go for days and this can be normal. By 4 years they should be like adults normal is 3 stools per day to wk.  

12

Management of simple constipation

Balanced diet + fluid + exercise

Is the patient impacted? (breakthrough diarrhoea, distention, palpable mass)

  • Yes - Commence disimpaction treatment then continue to maintenance
    • Escalation dose Movicol
    • Add stimulant laxative if not effective in 2 wks (Senna)
    • Substitute stimulant laxative +/- lactulose if movicol not tolerated
    • Warn carer that disimpaction may Sx of soiling + abdo pain
  • No - Commence maintenance treatment
    • Movicol adjusted to Sx response
    • Substitute stimulant if movicol not tolerated
    • Continue on therapy several wks after bowel return to normal
    • Dec dose slowly

13

Differentiating constipation overflow from functional encopresis

Functional Encopresis - repeated involuntary fecal soiling in the underpants that is not caused by organic defect or illness. 

Presence of constipation +/- pain - If the child has prior to the episode had painful constipation they may be hanging on the avoid the pain.

Skid marks - Children may start presenting with skid marks if they have overflow

Social issues - Children with functional encopresis are much more likely to have emotional/behavioural/social issues

Parent attitude - If a parent has a negative attitude about the problem likely functional encopresis

Ask about the situation surrounding the toilet - Is there a lot of negative emotion around it? Is there a lot of intereference? Probs functional encopresis

Urgency? - There usually isn't any in overflow, not sure about functional enc, but seems like there should be

14

Treatment of functional encopresis

Medical

  • Laxatives

Diet and fluid intake

  • 5 a day
  • Wholemeal bread and pasta
  • Lots of water
  • Exercise

Healthy toilet habits

  • Regular routine
  • Timed sits after meals

 

 

15

Aetiology, presenting Sx, diagnosis, management and complications of Hirschprungs 

Aetiology

Abscence of ganglionic cells from myenteric and submucosal plexus = narrow contracted segment of bowel

Triggering event unclear risk factors: family member w/ hirschprungs, male gender, having another inhereted condition

Sx

  • Failure to pass meconium/profound constipation
  • Abdo distention
  • Bilious vomiting
  • Failure to thrive in older children
  • Hirschprungs enterocolitis
    • Severe, life-threatening
    • Diarrhoea
    • Vomiting
    • Loss of appetite
    • Abdo cramping and pain
    • Fever
  • Other congenital disease e.g. down's or heart

Diagnosis

  • Digital rectal exam leads to release of bowels and flatulence = temporary easing of Sx
  • Suction rectal biopsy

Management

  • Surgical
    • Initial colostomy (creation of stoma)
    • Re connect non diseased bowel to anus

Complications

  • Perforation
  • Hirschprungs enterocolitis

16

Gastroenteritis: clinical features, management and assessment of hydration

Clinical features

  • DnV
  • Abdo pain
  • Pyrexia
  • Travel abroad is very suggestive
  • Recent contact w/ someone w/ similar issues also suggestive

Applies to under 5's

Assessing hydration (red flags)

  • Urine output (wet nappies)
  • Appears unwell/deteriorating
  • Lethargy
  • Altered responsiveness
  • Pale mottled skin
  • Dec skin turgour
  • Sunken eyes
  • Dry mucous membranes
  • Tachycardia
  • Tachyopnoea
  • Weak peripheral pulses
  • Prolonged CAP
  • If you have a baseline weight that helps with fluid resus

Management

  • Treat dehydration
    • See attached flow chart
  • Only give antibiotics if septicaemia or confirmed bacterial infection

 

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17

GORD: definition, pathophysiology, management and complication

Definition

Involuntary passage of gastric contents into oesophagus

Pathophysiology

Inappropriate relaxation of the lower oesophageal spincter as a result of functional immaturity. Fluid diet, lying horizontally, short intra-abdominal oesophagus also contribute.

Management

Non-medical

  • Parental reassurance that it should get better by 12 months age due to maturity
  • Sit head up 30 degrees after feed
  • Consider cows milk protein allergy

Medical

  • Add thickening agents to food (can be given for mild the rest are for more severe)
  • H2 antagonist (ranitidine)
  • PPI
  • Drugs to improve gastric emptying do not have a lot of evidence but may be used domperidone

Surgical (only in complicated, refractory GORDor oesophageal stricture)

  • Nissen fundoplication

Complications

  • SIDS (sudden infant death syndrome
  • Aspiration
  • Barrett's oesophagus

18

Bilirubin cycle

Don't need to know but helpful when looking at jaundice

There is also a good diagram in the paeds book pg 169

 

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19

Aetiology and pathogenesis of unconjugated jaundice

Can be physiological jaundice aka non-pathogenic (but still potentially dangerous) or pathogenic i.e. something is physically wrong. This jaundice present yellow rathen than green which in conjugated jaundice

 

Physiological

Aetiology

  • There is a lot of RBC break down at birth due to high Hb conc
  • Red cell life span in infant is 70 days (shorter than adults 120 days)
  • Heptatic bilirubin metabolism is less efficient in the first days of life
  • All these lead to high levels of unconjugated bilirubin in the blood = jaundice

Pathogenic

Aetiology/Causes

  • Increased lysis of RBC (increased haemoglobin release)
    • Rh/ABO incompatobility
  • Decreased uptake and conjugation of bilirubin
    • Pyloric stenosis
  • Increased enterohepatic reabsorption
    • Breast feeding jaundice i.e. dehyfdration from lack of feeding

Pathogenesis for both

  • This physiological jaundice may still be an issue as unconjugated bilirubin can cross BBB ==> kernicterus
  • Kernicterus: encephalopathy from deposits of unconjugated bilirubin. Usually occurs when there is more unconj bilirubil than albumin to take it safely to the liver. Initially presents with lethargy and poor feeding -> increased mm tone -> seizures -> coma. Complication include choreoathetiod CP, learning difficulties, sensorineural deafness

 

20

Aetiology and pathogenesis of conjugated jaundice

Conjugated (pathological) jaundice caused by cholestasis. So the bilirubin has been conjugated in the liver but it building up giving the jaundice more or a green appearance

Aetiology/Causes

  • Hepatocellular damage
    • Hepatitis
  • Biliary tree abnormalities
    • Biliary atresia

Pathophysiology

Conjugated bilirubin isn't toxic treat the cause

21

NICE guidelines for investigating and managing jaundice

Assessment is attached

 

Management

  • Phototherapy
  • Exchange transfusion

 

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22

Likely causes of jaundice and age of baby

Attached

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23

Importance of stool colour in child with jaundice

If pale and chalky this indicates that bilirubin is not getting to the gut in order to colour the poo. So it gives you a clue as to what is causing the jaundice. If they are jaundice with normal poo that probs means there is too much RBC break down, whereas if the poo is white it may indicate biliary atresia. 

24

S&S and investigations of biliary atresia

Hx

  • Normal birthweight
  • FTT
  • Mild jaundice
  • After meconium stools are pale and chalky

Ex

  • Splenohepatomegaly

Investigations

  • LFTs not always helpful
  • Fasting abdo USS may help
  • Radioisotope scan to see livere uptake and lack of passing into biliary tree
  • Liver biopsy may help b/c difficult to distinguish from hepatitis
  • Diagnosed at laprotomy by operative chiolangiography

 

25

Aetiology and presenting features of viral hepatitis

Aetiology

  • Hep A - faecal oral
  • Hep B - bodily fluid e.g. blood and semen, important cause of chronic liver disease world wide
  • Hep C - blood borne in CUTS
  • Hep D - co-infection with hep B necesarry. It is a dysfunctional virus - you get a for being a virus
  • Hep E - Faecal oral

Presenting features

  • Nausea
  • Vomiting
  • Abdo pain
  • Lethargy
  • Jaundice
  • Hepatomegaly +/- splenomegaly
  • Abdo tenderness on palpation

26

Diagnosis and management of coeliac disease

Diagnosis

  • Total immunoglobulin A (IgA)
  • IgA Tissue transglutaminase antibody (tTG)
  • Small intestine biopsy
  • (BUTTOCK WASTING BUZZ WORD FOR COELIAC)

Management

  • GF diet
  • Deitician referral

 

27

Hx w/ focus on food intolerance

GI symptoms? Food allergies usually do something to the GI tract. In first few weeks of life may present with blood in stool. 

Rash?

Angiodema?

Have you noticed that it is preciptated by any food? What did they last eat? What did they eat in the last few hours

Abdo pain/colic?

Have they got any other allergies/hayfever/asthma/eczema/atopy?

 

28

What's the difference between type 1 and type 2 hypersensitivity, in the context of food allergy

Type 1 

  • IgE mediated
  • Example - immediate cows milk allergy/allergic rhinoconjunctivus/anaphalaxis
  • Occurs 10-15 minutes after ingesting food
  • Sx include angiodema to anaphalxis

Type 2 

  • Non-IgE mediated IgG or IgM
  • Example cows milk allergy that occurs hours after ingestion
  • Occurs hours after ingestion and usually involves GI tract diarrhoea, vomiting etc.
  • May present as FTT

29

Define malabsorption

Disorders affecting the digestion or absorption of nutrients manifest as: abnormal stool, FTT, specific nutrient deficiency

30

Hx, Ex and DD for malabsorption

Malabsorption can be caused by a wide variety of things

  • GE
  • Coeliac
  • IBD
  • CF
  • Food intolerance
  • Hepatic issues
  • Poor diet
  • Parasitic infection

Hx

  • PCs
  • Stool: frequency, odor, what normal looks like, consitency, blood, 
  • Urinary: Sx, colour
  • Wght and Hgt
  • Jaundice?
  • Set off by certain food?
  • Recent travel?
  • What is their diet like?
  • FHx: coeliac, allergy, CF, IBD

Ex

  • Abdo

31

First line investigations for malabsorption

Assess nutrition

Hgt Wght

Hx + Ex and go from there

32

Define infantile colic and parental advice

Infantile colic: Excessive frequent crying in a baby that is otherwise well

Parental advice:

  • It is not your fault, there is nothing wrong with your parenting or your baby
  • It will eventually get better - colic usually resolves at 6mnths
  • Looks after your own well being and ask your friends and family for help
  • Hold you baby when crying
  • Hold them upright during feeding
  • Burp the baby after feeding
  • Rock the baby gently over your shoulder
  • Warm bath
  • Tummy massage
  • If you baby develops other sx take them to a GP
  • NHS website for more information

33

Management of infant w/ cow's milk protein intolerance

  • Remove cows milk from diet (hydrolysed/hypoallergenic milk)
  • Advice parents what to do incase of accidental ingestion (child dependent) antihistamines mild --> adrenaline severe
  • Advice parents on reading food labels

34

Age range and clinical features of toddler's diarrhoea

Age range: 1-5 mainly boys

Clinical features:

  • Chronic non-specific diarrhoea, diarrhoea is usually smelly
  • Pale and contains undigested food
  • Pain is unusual
  • No impact on hgt + wght
  • Otherwise well
  • Ex normal

35

Presenting features, pathology, systemic manifestation and treatment of UC

Pathology

  • Confined to colon
  • Mucosal/submucosal

Presenting features

  • Rectal bleeding
  • Diarrhoea 
  • Colicky pain
  • Wght loss hgt failure

Systemic manifestation

  • Growth restriction
  • Psychological impact
  • Erythema nodosum
  • Arthritis

Treatment

  • Aminosalicylates (balsalazide)
  • Disease in rectum and sigmoid colon can be treated with topical steriods
  • More aggressive disease is managed w/ systemic steriod for acute exacerbations and immunomodulatory therapy to maintain remission (azathiopine +/- corticosteriods)
  • Fulminating disease requires IV fluids and steriods
  • If remission is not achieved ciclosporin may be required
  • Surgery such as colectomy w/ ileostomy is only for fulminating disease which may be complicated by toxic megacolon
  • There is an increase incidence of colon cancer in adults w/ UC colonoscopy should be preformed 10 yrs after diagnosis

36

Presenting features, pathology, systemic manifestation and treatment of Crohns

Pathology

  • Can affect anywhere from mouth to rectum
  • Transmural
  • Focal
  • Sub acute
  • Strictures and fistulae may form
  • Usually affect ileum and proximal colon

Presenting features

  • Abdo pain
  • Diarrhoea
  • Wgt loss
  • Fever
  • Lethargy
  • May present as generally unwell and lethargic w/out GI sx

Systemic manifestation

  • Growth restriction
  • Delayed puberty
  • Psychological impact
  • Oral lesions
  • Perianal skin tags
  • Uveitis
  • Arthralgia
  • Erythema nodosum

Treatment

  • Nutritional therapy 6-8 wks
    • Replacement of diet with whole protein modular feeds
  • If ineffective systemic steriods
  • Immunosuppresants may be required for maintenance of remission e.g. methotrexate
  • Supplemental enteral nutrition usually via NG tube overnight can be helpful to correct growth issues
  • Surgery may be needed for complications e.g. obstruction, fistulae, abscesses

37

S&S and aetiologies of gastritis

Aetiology

  • Helicobactor

S&S

  • Abdo pain (epigastric) that wakes in the night
  • Hx of peptic ulceration in 1st degree relative
  • Nausea 

38

Treament of gastritic duodenal ulcers

  • Alcohol and smoking cessation
  • PPI (omeprazole)
  • If H.pylori is suggested then eradicationt therapy should be commenced
    • Amoxicillin
    • Metronidazole or clarithromycin

39

Define mesenteric adenitis and give DDs

Def: Swollen lymph glands in the mesentry

DD

  • Anything that causes abdo pain
  • Appendicitis
  • Constipation
  • IBS
  • Kidney stones
  • UTI
  • Gallstones
  • Period pain
  • GE
  • Stomach and duodenal ulcers