Flashcards in Gastroenterology ||| Deck (92):
What red flag symptoms should you check for in a vomiting child (11)?
1. Bile-stained vomit
3. Projectile vomiting in first few weeks of life
4. Vomiting at the end of paroxysmal coughing
5. Abdominal tenderness/pain on movement
6. Abdominal distension
8. Blood in stool
9. Severe dehydration, shock
10. Bulging fontanelle or seizures
11. Faltering growth
What is gastro-oesophageal reflux? What are its causes in infancy (4)?
The involuntary passage of gastric contents into the oesophagus.
1. Inappropriate relaxation of the lower oesophageal sphincter as a result of functional immaturity.
2. Predominantly fluid diet
3. A mainly horizontal posture
4. A short intra-abdominal length of oesophagus
What are the symptoms of gastro-oesophageal reflux (2)?
When does gastro-oesophageal reflux become GORD?
When the condition becomes a significant problem
What are the complications of gastro-oesophageal reflux (5)?
1. Faltering growth from severe vomiting
2. Oesophagitis - haematemesis, discomfort on feeding/heartburn, iron-deficiency anaemia
3. Recurrent pulmonary aspiration - recurrent pneumonia, cough or wheeze, apnoea in preterm infants
4. Dystonic neck posturing (Sandifer syndrome)
5. Apparent life-threatening events/SIDs
How is gastro-oesophageal reflux managed (3)?
1. non-medical in uncomplicated reflux
- parental reassurance, adding inert thickening agents to feeds and smaller more frequent feeds
2. Medical in significant GORD
- acid suppression with hydrogen receptor antagonist (ranitidine) or proton-pump inhibitors (omeprazole)
3. Surgical in children with complications unresponsive to intensive medical treatment or oesophageal stricture.
- a nissen fundoplication
What is infant colic? At what age does it occur?
Paroxysmal, inconsolable crying or screaming often accompanied by drawing up of the knees and passage of excessive flatus several times a day.
Typically occurs in the first few weeks of life.
How is infant colic managed (2)?
1. The condition is benign so support and reassurance should be given to parents.
2. If severe and persistent, it may be due to a cow's milk protein allergy and a 2-week trial of a protein hydrolysate (cows milk protein free) formula may be considered
What is recurrent abdominal pain and how does it present?
It is defined as pain sufficient to interrupt normal activities and lasts for at least 3 months
The pain is usually periumbilical and children are otherwise entirely well.
What are frequent causes of recurrent abdo pain?
2. Functional abnormalities of gut motility
-Coeliac disease (less common)
What is an abdominal migraine?
What questions in the history could you ask to check for this (4)?
Abdominal pain associated with headaches
1. Where is the pain?
-Presents as an attack of the midline
2. Associated symptoms
- vomiting and facial pallor
3. Any family or personal history of migraines
4. How often do you get it?
- can have a few weeks without symptoms, then it comes on for several hours-days
What is an IBS?
What questions in the history could you ask to check for this (7)?
Altered GI motility and an abnormal sensation of intra-abdominal events
1. Is there any family history of IBS?
2. Where is the pain
3. is it relieved by defecation?
4. do you often have explosive, loose or mucousy stools?
5. Do you have bloating?
6. Is there a feeling of incomplete evacuation?
7. What are bowel movements like?
-often constipated, alternating with normal/loose stools
What questions in the history could you ask to check for duodenal ulcers (4)?
1. Where is the pain?
-epigastric, and radiates to back
2. Does the pain ever wake you up at night?
3. Is there any history of peptic ulceration in a first-degree relative?
4. Are there any other associated symptoms?
-nausea, early satiety, bloating, postprandial vomiting, delayed gastric emptying
What are the investigations you should do when someone presents with recurrent abdominal pain (6)?
1. Full history and examination - check for anal fissures
2. Check child's growth
3. Urine microscopy and culture for UTI
4. Abdominal US for gall stones and pelvi-ureteric junction obstruction
5. Coeliac antibodies
6. Thyroid function tests
What is the most frequent cause of gastroenteritis in developed countries?
What other viruses can cause outbreaks (5)?
Adenovirus, norovirus, calicivirus, coronavirus, astrovirus
What symptom can indicate a bacterial cause of gastroenteritis?
What are the bacteria that can cause gastroenteritis and their associated symptoms (3)?
Blood in stools
1. Campylobacter jejuni - severe abdo pain
2. Shigella and salmonella- blood and pus in stool, pain and tenesmus. Shigella may give a high fever
3. Cholera and E.coli infection - profuse, rapidly dehydrating diarrhoea
What parasites cause gastroenteritis (2)?
Giardia and Cryptosporidium
How does gastroenteritis present (2)?
Sudden change to loose or watery stools often accompanied by vomiting
What is the most serious complication of gastroenteritis?
Dehydration leading to shock
What groups of children are at an increased risk of dehydration (5)?
1. infants, particularly those under 6 months or with low birthweight
2. if they have passed 6 or more diarrhoeal stools in the previous 24 hours
3. if they have vomited 3 or more times in the previous 24 hours
4. if they have been unable to tolerate or not been offered extra fluids
5. if they have malnutrition
How is the degree of dehydration assessed (3)?
1. no clinically detectable dehydration (usually <5% loss of body weight)
2. clinical dehydration (usually 5-10% loss of body wight)
3. shock (usually >10% loss of body weight)
How is dehydration managed (3)?
1. oral rehydration, continue breastfeeding
2. if shock - urgent admission, iv fluids
3. Abx only indicated if there is suspected/confirmed sepsis
What are the clinical features of shock from dehydration in an infant (8)?
1. Decreased consciousness
2. Sunken fontanelle
3. Dry mucous membranes
4. Eyes sunken and tearless
6. Prolonged cap refill time
7. reduced urine output
8. cold extremities
How do you define malabsorption?
Disorders affecting the digestion or absorption of nutrients
How does malabsorption present (3)?
1. Abnormal stools - float and are smelly
2. Poor weight gain or faltering growth in most but not all cases
3. Specific nutrient deficiencies, either singly or in combination
What is the pathophysiology of coeliac disease?
An enteropathy in which the gliadin fraction of gluten and other related prolamines in wheat, barley and rye provoke a damaging immunological response in the proximal SI mucosa.
As a result, the rate of migration of enterocytes from the crypts is massively increased but insufficient to compensate for increased cell loss from villous tips.
Villi become shorter and then absent, leaving a flat mucosa.
What is the presentation of coeliac disease (5) and at what age does it usually present at?
1. Faltering growth
2. Abdominal distension
3. Buttock wasting
4. Abnormal stools
5. General irritability
Presents at 8-24 months of age after introduction of wheat-containing weaning foods
How is coeliac disease diagnosed (3)?
1. specific serology screening tests i.e. anti-tTG, EMA and IgA
2. demonstration of increased intraepithelial lymphocytes and variable degree of villous atrophy and crypt hypertrophy on SI biopsy performed endoscopically
3. Resolution of symptoms and catch-up growth upon gluten withdrawal.
How is coeliac disease managed (4)?
1. Removal of all products containing wheat, rye and barely.
2. Supervision by a dietician is essential.
3. A gluten challenge can be done later in childhood to demonstrate continuing susceptibility of the SI mucosa to damage by gluten.
4. Annual blood testing can be considered
What is toddler diarrhoea/chronic non-specific diarrhoea? How does it present (2)?
The most common cause of persistent loose stools in preschool children.
1. Characteristically, the stools are of varying consistency, sometimes well formed, sometimes explosive and loose.
2. The presence of undigested vegetables in stools is common.
What are the causes of toddler diarrhoea/chronic non-specific diarrhoea (3)?
1. Excessive ingestion of fruit juice
2. Undiagnosed coeliac disease
3. temporary cow's milk allergy following gastroenteritis
What is the management of cow's milk allergy?
Trial of a cow's milk protein free diet
What are the presenting features of Crohn's (4)?
1. General ill health
2. Growth failure
3. Intestinal symptoms
4. Extra-intestinal symptoms
-oral lesions or perianal skin tags
What is the pathology of Crohn's? Which part of the bowel does it usually affect?
It is a transmural, focal, subacute or chronic inflammatory disease.
It usually affects the distal ileum and proximal colon. Initially, they become acutely inflamed and thickened, subsequently, the bowel forms strictures and fistulae can form between the loops of bowel or between bowel+skin/other organs
What are the clinical signs of Crohn's (3)?
1. Presence of raised inflammatory markers (platelet count, erythrocyte sedimentation rate, CRP)
2. iron-deficiency anaemia
3. low serum albumin
What is the management of Crohn's (4)?
1. Immunosuppressant medication to obtain remission
-azathioprine, mercaptopurine, methotrexate
2. Anti-tumour necrosis factor agents when conventional treatments don't work
-infliximab or adalimumab
3. Nutritional therapy
4. Surgery for complications of Crohn's i.e. obstruction, fistulae, abscess or severe localised disease.
What are the presenting features of ulcerative colitis (5)?
1. rectal bleeding
3. colicky pain
4. weight loss and growth failure may occur but less than in Crohn's
5. Extra-intestinal complications
What is the treatment of UC (5)?
1. In mild disease, aminosalicylates are used for induction and maintenance therapy.
2. For disease confined to rectum and sigmoid colon (rare in children) can be managed by topical steroids
3. More aggressive disease needs systemic steroids for acute exacerbations and immunomodulatory therapy e.g. azathioprine to maintain remission
4. Severe fulminating disease is a medical emergancy and requires treatment with iv fluids and steroids. If this fails to induce remission, ciclosporin may be used
5. Severe fulminating disease requires colectomy with an ileostomy or ileorectal pouch
What is the relationship between H. pylori and abdominal pain in children?
It is associated with antral gastritis and duodenal ulcers
How are peptic ulcers treated (2)?
1. Proton-pump inhibitors e.g. omeprazole
If they have H. pylori infection then add:
2. Eradication therapy
metronidazole or clarithromycin
Clinical presentation of gastritis (4)?
1. Abdominal pain
2. Nausea and vomiting
3. Early satiety
What are the various things that parents using the word "constipation" describe (3)?
1. Decreased frequency of defecation
2. The degree of hardness
3. Painful defecation
What is the pragmatic definition of constipation?
The infrequent passage of dry hardened faeces often accompanied by straining or pain and bleeding associated with hard stools.
Questions in the history which can differentiate between constipation and Hirschprung's disease (3)?
1. Has there been failure to pass meconium within 24 hours of life?
2. Is there gross abdominal distension?
3. Is there any bile-stained vomiting?
What is the management of simple constipation (2)?
1. Maintenance laxative therapy
2. Extra fluids
What is Hirschsprung disease?
When does it present?
How does it present (3)?
It is the absence of ganglion cells from the myenteric and submucosal plexuses of part of the large bowel results in a narrow, contracted segment
Presentation is in the neonatal period
1. Intestinal obstruction heralded by failure to pass meconium within the first 24 hours of life.
2. Abdominal distension
3. Bile-stained vomiting develops.
How is Hirschsprung disease managed?
Surgery - initial colostomy followed by anastomozing normally innervated bowel to the anus.
What is a severe, life-threatening complication of Hirschsprung disease?
Hirschsprung enterocolitis in the first few weeks of life. It is a condition of intestinal inflammation characterized clinically by fever, abdominal distention, diarrhea and sepsis
What is functional encopresis? What is its pathophysiology?
It is voluntary or involuntary fecal soiling in children who have usually already been toilet trained. It is commonly caused by constipation, by reflexive withholding of stool, by various physiological, psychological, or neurological disorders
Stool that stays in the colon for a long time gets hardened, which becomes even harder and more painful to pass. The hardened stool continues to build up and stretches the colon or rectum to the point where the normal sensations associated with impending bowel movements do not occur. Eventually, softer stool leaks around the blockage and cannot be withheld by the anus, resulting in soiling.
What is constipation and overflow?
In long-standing constipation, the rectum becomes overdistended, with a subsequent loss of feeling the need to defecate, Involuntary soiling may occur as contractions of the full rectum inhibit the internal sphincter, leading to overflow.
How are children and parents supported regarding soiling and encopresis (3)?
1. It should be explained to the child and parents that the soiling is involuntary and that recovery of normal rectal size and sensation can be achieved but can take a long time.
2. evacuate the overloaded rectum completely using stool softeners
3. followed by maintenance treatment to ensure ongoing regular, pain-free defecation.
What is a food allergy? What immunoglobulins is it caused by?
What is a food intolerance?
A food allergy occurs when a pathological immune response is mounted against a specific food protein.
-can be non-IgE mediated
A food intolerance is a non-immunological hypersensitivity reaction to a specific food
What is a primary food allergy? How does it present?
What are the common allergens in infants and older children?
Where children react on first exposure.
Presentation varies with agent and the child's age
Infants - milk, egg and peanut
In older children - peanut, tree nut, fish and shellfish
What is a secondary food allergy? How does it present?
Due to cross-reactivity between proteins present in fresh fruits/vegetables/nuts and those present in pollens.
It usually leads to mild allergic reactions, often causing an itchy mouth but no systemic symptoms.
How does a non-IgE food allergy typically present (5)?
It occurs hours after ingestion and usually involves the GI tract:
3. abdo pain
4. sometimes faltering growth
5. sometimes presents with blood in the stools in the first few weeks of life from proctitis or with severe repetitive vomiting in an infant which can result in shock.
How does an IgE-mediated food allergy present?
History of allergic symptom varying from urticaria to facial swelling to anaphylaxis usually occurring 10-15 minutes (up to 2 hours) after ingestion of a food.
What is key in the history of food allergy?
If typical symptoms occur following exposure to a particular food
What are the best tests to confirm an IgE-mediated food allergy (2)?
1. skin-prick test
2. measurement of specific IgE antibodies in the blood
How are non-IgE mediated food allergies diagnosed (3)?
1. Clinical history
3. If indicated, endoscopy and intestinal biopsy may be obtained - the presence of eosinophilic infiltrates
What is the gold-standard investigation in cases of doubt in diagnoses both IgE-mediated and non-IgE-mediated food allergies (2)
1. Exclusion of the relevant food under a dietitian's supervision
2. Followed by a double-blind placebo-controlled food challenge.
What is the management of a food-allergic child (3)?
1. Avoidance of the relevant foods
2. The advice of a paediatric dietitian is essential
3. Making sure the child and family is able to manage an allergic attack - written self-management plans and adequate training are essential
How is a mild and severe food allergy reaction managed?
mild: non-sedating antihistamines
severe: adrenaline im
What are the ddx of malabsorption (5)?
1. Short bowel syndrome
2. Cholestatic liver disease/biliary atresia
3. Loss of terminal ileal function
4. Exocrine pancreatic dysfunction e.g. CF
5. Small-intestinal mucosal disease
-specific transport defects
Questions in history to determine ddx of malabsorption (4)?
1. When did it present?
-Coeliac and CF are early, around 8-24 months for coeliac and 6-8 months for CF
2. Did it occur with weaning onto solid wheat-containing foods?
3. Has there been any surgery from congenital gut defects/major trauma?
-short bowel syndrome
4. Any family history of coeliac/crohn's/CF?
What parasites can cause malabsorption (5)?
4. Whipple's disease
5. Nematode infection
What is a first-line investigation in malabsorption?
Reliable dietetic assessment
What is nutrition?
Nutrition is the intake of food, considered in relation to the body’s dietary needs.
Good nutrition – an adequate, well balanced diet combined with regular physical activity – is a cornerstone of good health. Poor nutrition can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity
Where can women get support/advice on breastfeeding (6)?
2. Health visitor
6. breast feeding peer support programs
How long should breastfeeding be continued for?
According to WHO - exclusive breastfeeding until 6 months, then breastfeeding + food until 2 years of age
What is a "follow-on" formula?
Formula that contains more protein and sodium than infant formula and, in contrast to cow's milk, are fortified with iron and vitamins.
Up until the age of 5, children should have what type of cow's milk?
Which children should receive specialised infant formula (6)?
2. those with cow's milk protein allergy
3. lactose intolerance
5. neonatal cholestatic liver disease
6. following neonatal intestinal resection
What is the specialised infant formula composed of (3)?
1. protein derived from hydrolyzed cow's milk protein, amino acids or soya
2. Carbohydrate is a glucose polymer
3. fat is a combination of medium-chain and long-chain triglycerides
What is weight faltering?
It is suboptimal weight gain in infants or young children. If prolonged can lead to reduction in height or length and head growth, resulting in delayed development
What is a graphical definition of weight faltering?
A sustained drop down two centile spaces
What are the causes of growth faltering (5)?
1. Inadequate intake
-inadequate availability of food
-poor maternal education
-underlying swallowing/sucking pathology
-chronic illness leading to anorexia
2. Inadequate retention
4. Failure to utilize nutrients
5. Increased requirements
What questions in the history should be asked in weight faltering?
1. Dietary history (6)
2. Other qs (5)
1. hx of milk feeding
2. age at weaning
3. range and type of foods now taken
4. mealtime routine and eating and feeding behaviours
5. a 3-day food diary will provide a more detailed and accurate picture of intake
6. if possible, observe a meal being taken
1. was the child preterm or had IUGR?
2. is the child well with lots of energy or does the child have other symptoms such as diarrhoea, vomiting, cough, lethargy?
3. the growth of other family members and illnesses in fam?
4 is child's development normal?
5. any psychosocial problems at home?
Management of weight faltering (5)
1. using mealtime observations and food diaries
2. health visitors can assess and support families to improve feeding and increase calorie intake
3. paediatric dietician is helpful in assessing the quantity and composition of food intake
4. SALT for feeding disorders
5. In children under 6 months of age with severe weight faltering, hospital admission can be necessary for active refeeding
What are the presenting features of Kwashiorkor (2)?
1. Generalised oedema
2. Severe wasting
What is Kwashiorkor?
A severe protein-energy malnutrition in some developing countries, where infants are weaned late from the breast and the young child's diet is high in starch?
What is the MUST tool?
‘MUST’ is a five-step screening tool to identify adults, who are malnourished, at risk of malnutrition
(undernutrition), or obese.
Step 1 BMI
Step 2 Percentage unplanned weight loss and score
Step 3 Establish acute disease effect and score
Step 4 Add steps 1-3 for overall score
Step 5 Use local guidelines to develop care plan
How is severe acute malnutrition defined as (3)?
1. Weight for height - more than 3 sd
2. Mid-upper-arm circumference (MUAC) - less than 115mm in children 6 months-5 years old
3. Bilateral oedema
What are the reference values for energy and protein requirements in age 0-6 months and 6-12 months?
Energy - 115 kcal/kg per 24 h
Protein - 2.2 g/kg per 24 h
Energy - 95 kcal/kg per 24 h
Protein - 2 g/kg per 24 h
What are the symptoms and signs of overfeeding (3)?
1. discomfort and crying
2. gastric reflux
3. loose stools
Causes of prolonged persistent neonatal jaundice?
1. breastmilk jaundice
3. haemolytic anaemia
5. high gastrointestinal obstruction
6. Crigler-Najjar syndrome
1. Bile duct obstruction
2. Neonatal hepatitis syndrome
-inborn errors of metabolism
3. Intrahepatic biliary hypoplasia
What is biliary atresia?
How does it present (5)?
At what age does it usually present?
There is progressive fibrosis and obliteration of the extrahepatic and intrahepatic biliary tree
1. mild jaundice
2. pale stools
3. normal birthweight followed by faltering growth
Presents 1st few weeks of life
What investigations would you do for biliary atresia (5)?
-raised conjugated bilirubin
3. fasting abdo USS
-contracted or absent gallbladder
4. diagnosis confirmed by a cholangiogram (ERCP or operative) which fails to outline a normal biliary tree
5. Liver biopsy
What are the NICE recommendations for the investigation of neonatal jaundice?
History from the carer (6)
Evaluate extent of jaundice
Ask carer about:
1. obs hx
2. age at onset and duration of jaundice
3. Number of wet or dirty nappies in a day (to assess the state of hydration).
4. Also specifically ask about the presence of dark urine and/or pale stools.
5. Family history of relevant conditions — for example significant haemolysis (including glucose-6-phosphate-dehydrogenase deficiency).
6. Ask whether any siblings or close family members have required hospital treatment such as phototherapy or exchange blood transfusion for neonatal jaundice.
Examine the neonate to check for:
1. Signs of illness (for example lethargy, fever, vomiting, significant weight loss, irritability)
2. Appropriate weight gain (compared with previous measurements if available).
3. Evidence of bruising (for example cephalhaematoma following ventouse delivery)
Evaluate the extent of jaundice.
Do not attempt to use a visual assessment of jaundice to estimate bilirubin level (jaundice in the neonate spreads from the head downwards with increasing bilirubin levels)
What are the NICE recommendations for the management of neonatal jaundice (4)?
1. Emergency admission if:
-features of encephalitis, unwell, pale stools and dark urine etc
2. Otherwise, if transcutaneous bilirubin measurements are available in primary care, record the level within 6 hours and manage according to local protocols. If not, transfer to paediatric unit
3. Reassure parents and carers that:
Neonatal jaundice is common and is usually transient and harmless.
4. Treatment may be:
- no treatment
- treatment of underlying infection
- exchange transfusion
- surgery e.g. for biliary atresia
What does the presence of pale stools and dark urine suggest?
A obstructive/post-hepatic cause of jaundice
What are the clinical features of acute viral hepatitis (8)?
4. abdominal pain
6. a large tender liver
8. elevated liver transaminases