Gastroenterology

Question 1

dDx vomiting infant

Answer 1

Pyloric stenosis
GORD
Possetting
Gastroenteritis
Small bowel obstruction Systemic/localised infection
Hirshsprungs
Oesophageal fistula
Galactosaemia

Question 2

dDx vomiting adolescent

Answer 2

Raised ICP
Migraine
Bulimia
Pregnancy (test all girls >12y)

Question 3

Features pyloric stenosis

Answer 3

Characterised by gradual thickening of the pyloric muscles
More common in boys and first borns
Typically non-bilious vomiting at 2-8 weeks
Progressive frequency and forcefulness resulting in projectile vomiting following feeds
Loss of interest in feeds
Palpable pyloric mass in RUG with a full stomach
Visible gastric peristalsis from left to right
Hypochloremia, hypokalemic alkalosis, with increased bicarbonate

Question 4

US pyloric stenosis

Answer 4

hypertrophy: thickness >4mm; length >18mm; failure fluid passage beyond pylorus

Question 5

Mx Pyloric stenosis

Answer 5

Correct dehydration and electrolyte imbalances
Definitive treatment is myomectomy via RUQ or supraumbilical incision.
Normal feeding resumes after 6 hours

Question 6

Features GORD

Answer 6

Typically following feeds, arching back, worse lying down after feeds, better sitting up
Address feeding techniques and positioning
Associated with cerebral palsy and neurodevelopmental disorder

Question 7

Mx GORD

Answer 7

Thickening of feeds ,e,g, gaviscon
Acid suppression .e.g. Ranitidine, omeprazole
In severe cases surgery may be indicated- Nissens procedure high failure

Question 8

Features possetting

Answer 8

Non-forceful regurgitation, milky vomit, low volumes

Parental reassurance

Question 9

Features gastroenteritis

Answer 9

Inflammation of the bowel secondary to infection
Typically rotavirus in children: now on immunisation schedule
Sudden onset diarrhea and vomiting, typically affected contacts, weight loss, poor feeding

Question 10

Cx gastroenteritis

Answer 10

Post gastritis syndrome: watery diarrhoea on reintroduction of normal diet, initiate oral rehydration

Question 11

Mx gastroenteritis

Answer 11

Stool culture if immunocompromised, blood/mucus in stool or evidence of sepsis
Oral rehydration solution and isolation to limit spread

Question 12

Features small bowel obstruction

Answer 12

May be recognised antenatally
Persistent bile stained vomiting and increasing prominent abdominal distention
Initial passage of meconium and no further stool

Question 13

Features duodenal atresia

Answer 13

Commonly associated with down’s syndrome and congenital malformations
Double bubble on X Ray

Question 14

Mx dudodenal atresia

Answer 14

NG decompression

Surgical correction

Question 15

Features jejunum/ileum atresia

Answer 15

secondary to vascular occlusion in utero

may include multiple atretic segments

Question 16

Features malrotation

Answer 16

Abnormal rotation during development
DJ flexure on right of midline
Volvulus formed when mesentery twists on own axis leading to vascular compromise and mechanical obstruction
Diagnosis by upper GI contrast

Question 17

Mx malrotation

Answer 17

Ladd’s procedure to correct and removal of appendix to prevent later confusion with appendicitis

Question 18

Features meconium ileus

Answer 18

Thickened impacted meconium in lower ileum

Commonly in cystic fibrosis

Question 19

Mx meconium ileus

Answer 19

Enema and rectal washout

Laparotomy with temporary ileostomy

Question 20

Features hirschsprungs

Answer 20

Absence of ganglion cells in mesenteric and submucosal plexus
Neonatal presentation as failure/delay in meconium passage
Abdominal distention, bile stained vomiting
Release of flatus and stool with PR examination

Question 21

Mx hirschsprungs

Answer 21

Rectal biopsy shows absence of ganglion cells with large ACh positive nerve trunks
Definitive management: colostomy with anastomosis normally innervated bowel to the anus

Question 22

Features oesophageal fistula

Answer 22

Persistent salivation, drooling, coughing and choking, especially when fed
Associated with VACTERL abnormalities
High risk of aspiration

Question 23

Mx oesophageal fistula

Answer 23

NG tube passed and check on Xray to confirm structure

Surgery is definitive treatment

Question 24

dDx recurrent abdominal pain

Answer 24

Abdominal migraine
Irritable bowel syndrome
Peptic ulceration
Gastritis
Esoinophilic oesophagitis
functional abdominal pain

Question 25

dDx acute abdominal pain

Answer 25

``` Colic Mesenteric adenitis DKA Acute appendicitis HSP UTI Lower lober pneumonia Interssusception Meckel's diverticulum ```

Question 26

dDx change in stools

Answer 26

``` Inappropriate diet Celiac disease Cystic fibrosis Cow's milk protein intolerance Toddlers diarrhoea IBD Constipation Parasitic infection ```

Question 27

Features abdominal migraine

Answer 27

Idiopathic disorder with recurrent episodes midline abdominal pain Associated with GI features Similar triggers to normal migraines Advice and analgesia Management with rescue and prophylactic medications Likely to later develop migraines

Question 28

Features IBS

Answer 28

Frequent episodic relapses May be precipitated by infection Excessively forceful contraction and low tolerance of stretch Often family history Periumbilical abdominal pain worse before and relieved by defecation Explosive loose stool with mucus, often alternating with constipation Abdominal bloating and feeling of incomplete defecation Symptomatic control by dietary changes and antispasmodics

Question 29

Features peptic ulceration

Answer 29

Uncommon in children Associated with H.Pylori Testing by endoscopy and blood/stool sample Classically epigastric pain, waking at night, radiation to the back, occurring after eating or emptying stomach

Question 30

Mx peptic ulceration

Answer 30

H. Pylori eradication therapy: metronidazole, clarithromycin and amoxicillin Acute presentation is perforation: endoscopy for coagulation therapy and haemostatic clips

Question 31

Features gastritis

Answer 31

Inflammation of the stomach lining due to food intolerance, medication or infection Risk factors include stress, poor diet, illness, NSAIDs, caffeine Nausea, vomiting, upper abdo pain, loss of appetite, abdo distention, flatulence Mild cases require no treatment

Question 32

Features eosinophillic oesophagitis

Answer 32

Eosinophilic inflammatory infiltrate secondary to food or aeo-allergens Features of esophageal dysfunction Males with atopic history Feeding difficulty or refusal, vomiting and regurgitation, retrosternal and epigastric pain, dysphagia, food impaction

Question 33

Mx eosinophilic oesophagitis

Answer 33

Endoscopic biopsy, peripheral IgE raised Subset of patients responsive to PPI Dietary restriction and exclusion diet in young children Oral corticosteroids .e.g. Fluticasone

Question 34

Features Colic

Answer 34

Unknown mechanism Discrete episodes of crying and drawing up legs/arching back in young infants Typically excessive flatus Sel resolves by 6-12 months

Question 35

Features mesenteric adenitis

Answer 35

Common in children under 15 years Mesenteric lymph node inflammation following viral infection Acute abdominal pain and associated GI symptoms, with pharyngitis and cervical lymphadenopathy- clinical diagnosis Alagaesia and hydration Self limiting

Question 36

Features acute appendicitis

Answer 36

Acute inflammation of the appendix due to obstruction of the lumen Uncommon in children <3 months Associated with serous free fluid in abdomen visible on US Periumbilical colicky pain shifting to the RIL becoming constant and severe Aggravated by movement Tenderness and guarding with rebound tenderness on palpation Frequently nausea, vomiting and occasionally anorexia High grade fever suggests perforation

Question 37

US appendicitis

Answer 37

US is low sensitivity but shows thiked non compressible appendix with increased blood flow

Question 38

Mx Appendicitis

Answer 38

Appendicectomy | In perforation full wash out followed by 5-10 days of antibiotics

Question 39

Features Meckels Diverticulum

Answer 39

Typically causes painless bleeding PR Ileal remnant of vitelline duct 40-60cm proximal to the ileocaecal valve Technetium scan demonstrated increased uptake Surgical resection with adjacent ileal segment

Question 40

Features celiac disease

Answer 40

Autoimmune inflammatory response to gliadin fraction of gluten Age of presentation dependant on gluten introduction: classically 6 months-3 years Presents with profound malabsorption: fatigue, weight loss, chronic diarrhoea, flatulence, pale stools, buttocks wasting Associated with other autoimmune conditions

Question 41

Ix celiac disease

Answer 41

Diagnosis by positive serology and mucosal change on endoscopy Iron/folate deficiency anaemia, vitamin B12 deficiency, elevated transaminase following gluten in diet

Question 42

Mx celiac disease

Answer 42

Gluten free diet: reintroduction may be trialled in later childhood Follow up to ensure adherence to diet

Question 43

GI manifestations of cystic fibrosis

Answer 43

Increased viscosity of secretion affecting lung and pancreas Bulky stools resulting in rectal prolapse Steatorrhoea due to aberrant pancreatic function and poor fat absorption Malabsorptive conditions cause failure to thrive

Question 44

Features cow's milk protein intolerance

Answer 44

Onset typically when changing to formula feed Child becomes irritable, vomiting, swelling/rash around mouth Switch to different formula Common childhood food allergy Trial of milk in older childhood usually successful

Question 45

Features toddlers diarrhoea

Answer 45

Otherwise well child Due to increased gastric motility in younger children Classically diarrhoea with whole pieces of vegetables Restrict fruit juices nand increase dietary fibre Usually self resolves

Question 46

Features chrons disease

Answer 46

Typically affects distal ileum and proximal colon Areas of acutely inflamed and thickened bowel with development of strictures and fistulas Abdo pain, diarrhoea, weight loss, pubertal delay, fever, lethargy

Question 47

Ix Chrons disease

Answer 47

Raised platelet, ESR, CRP, iron deficiency anaemia, low serum albumin Biopsy required for diagnosis

Question 48

Mx Chron's disease

Answer 48

Remission may be induced by dietary change: polymeric diet for 6-8 weeks Systemic steroids Immunosuppression required to maintain remission

Question 49

Features ulcerative colitis

Answer 49

Recurrent inflammatory ulceration of colon mucosa Rectal bleeding, diarrhea, colicky pain, weight loss, growth failure Diagnosis by endoscopy

Question 50

Mx Ulcerative colitis

Answer 50

Aminosalicylates .e.g. Mesalazine for induction of remission and maintenance Disease confided torectum and sigmoid colon may be controlled by steroids

Question 51

Features constipation

Answer 51

Common problem in childhood Dietary changes will typically not have any impact Possibly a faecal mass palpable on examination

Question 52

Red flags constipation

Answer 52

failure to pass meconium within 24 hours, faltering growth, gross abdominal distention, lower limb deformity, sacral dimple, abnormal anus, bruising/fissures, fistulae, abscess

Question 53

Mx constipation

Answer 53

Self resolves in some children Long standing constipation can result in soiling and loss of sensation Disimpaction regimen with movicol paediatric plan in escalating doses, with addition of stimulant .e.g. Senna Maintenance therapy by polyethylene glycol Good toileting behaviour important

Question 54

Features intussusception

Answer 54

``` invagination of one portion of the bowel into the lumen of adjacent bowel Usually ileo-caecal region 6-18m boys>girls paroxysmal abdominal colic pain draws up knees pallor vomiting red currant jelly stool (late sign) Sausage shaped mass in RUQ ```

Question 55

Ix intussusception

Answer 55

target like mass on US

Question 56

Mx intussusception

Answer 56

air insufflation under radiological control | Failure of insufflation or peritonitis- surgery