Gastroenterology Flashcards

Question

Signs and symptoms of overfeeding

Answer 1

Baby gains average/greater than average weight >7 heavily wet nappies per day Frequent sloppy, foul-smelling bowel motions Extreme flatulence Large belching Milk regurgitation Irritability Sleep disturbances Baby still displays healthy growth: unlike colic/reflux/milk protein intolerance/lactose intolerance

Answer 2

``` Sleep deprivation Misinterpreting baby’s desire to suck as hunger An active sucking reflex Feeding too quickly Feeding sleep association Overlooking/ignoring satiety cues ```

Answer 3

Infant: 4x a day 1y: 2x a day By 4y: same as adult

Answer 4

Failure to pass meconium with 24hrs: Hirschprung’s disease Failure to thrive/growth failure: hypothyroidism, coeliac disease, other causes Gross abdominal distension: Hirschprung’s disease or other GI dysmolitiy Abnormal lower limb neurology or deformity: lumbosacral pathology Sacral dimple above natal cleft over spine: spina bifida occulta Abnormal appearance/position/patency of anus: abnormal anorectal anatomy Perianal bruising/multiple fissures: sexual abuse Perianal fistulae, abscesses or fissures: perianal Crohn's disease

Answer 5

Encouragement/close supervision/psychological support Faeces not palpable per abdo: balanced diet & sufficient fluids + maintenance laxatives Faeces palpable: 1) macrogol laxative + elecrolytes (2w) If not spontaneously passing stool: 2) stimulant laxactive +/- osmotic laxative If no success: 3) consider enema +/- sedation or manual evacuation under general anaesthetic

Answer 6

Toilet trained child (>4yrs) soiling their clothes | With/without constipation and overflow

Answer 7

Never being toilet trained, toilet phobia, manipulative soiling, IBS

Answer 8

Soft stools may be around the faeces | The colon is completely full, so stools force their way out

Answer 9

GP usually by the first line Most see a paediatric gastroenterologist Psychological and parental help in training the child and parent to reward good behaviours Wide variety of online information and even encopresis support groups for parents

Answer 10

The absence of ganglion cells from the myenteric and submucosal plexuses in the large bowel --> narrow and contracted segments the abnormal bowel extends from the rectum for a variable distance Proximally and ends in a normally innervated, dilated colon Causes by a failure of ganglion cells to migrate into the hindgut Leads to an absence of coordinated bowel peristalsis and functional bowel obstruction at the junction between normal bowel and distal aganglionic bowel 75% of cases only affect the rectosigmoid but 10% affect the entire colon

Answer 11

Neonatal period: intestinal obstruction, failure to pass meconium abdominal distention and bile-stained vomiting develops later PR: a narrowed segment and withdrawal of examining finger may release a gush of liquid stool and flatus Severe, life-threatening Hirschsprung enterocolitis: 1st few weeks of life due to C.difficile infection In later childhood: chronic constipation, associated with abdominal distension, usually without soiling, growth failure may also be present

Answer 12

AXR: distal intestinal obstruction | Rectal biopsy: no ganglion cells in the submucosa

Answer 13

Surgical management: single stage pull-through in the neonatal period managing initial intestinal obstruction with rectal washouts 3 stage procedure is still used: Defunctioning colostomy & multiple biopsies to confirm the site of the transition zone Pull-through procedure to bring ganglionic bowel down to the anus Closure of colostomy

Answer 14

Enterocolitis: a gastroenteritic illness characterised by abdominal distension, bloody watery diarrhoea, circulatory collapse and septicaemia Mortality is 10%

Answer 15

``` Temperature: >38 (<3 months), >39 (>3 months) SOB, tachypnoea Altered state of consciousness Neck stiffness Bulging fontanelle Non-blanching rash Blood and/or mucus in stool Bilious vomit Severe abdominal pain Abdominal distension/rebound tenderness ```

Answer 16

60% caused by rotavirus in the developed world Stool sample: septicaemia suspected, blood/mucus in stool, child is immunosuppressed MCS: recent travel abroad, not improved in 7 days, uncertain diagnosis

Answer 17

Rehydration therapy: replacement and maintenance Continue breastfeeding if possible Oral rehydration solution I.V. fluids: 0.9% sodium chloride Monitor plasma electrolytes, urea, creatinine, glucose: consider i.v. potassium supplement Look for dehydration symptoms: altered responsiveness, urine output, tachycardia, tachypnoea, reduced skin turgor

Answer 18

Depends where the allergic inflammation is Upper GI: vomiting, feeding adversion, pain Small intestine: diarrhoea, abdominal pain, protein-losing enteropathy, failure to thrive Large intestine: diarrhoea, acute colitis with blood and mucus in stools and rarely chronic constipation May occur in breastfed infants: reaction is to cow’s milk protein secreted in breast milk following maternal ingestion --> presents as allergic colitis

Answer 19

Limit cow’s milk & soy protein intake: hydrolysed formula & maternal exclusion Elemental formula may be required Avoid goat/sheep’s milk as substitute: 25% develop an allergy to these due to crossreactivity Similar cross-reactivity occurs with soy milk and is not recommended <6 months anyway After weaning introduce a cow’s milk protein free diet Supplement oral calcium if required Consider cow’s milk protein challenge after 6-12 months

Answer 20

Chronic non-specific diarrhoea: commonest cause of persistant loose stools in preschool children Stools vary in consistency: presence of undigested veg common, pale, foul-smelling Thriving child, no precipitating dietary factors Loose stools likely due to intestinal dysmotility, no malabsorption Most grow out of symptoms by 5yo: achieving faecal continence may be significantly delayed

Answer 21

``` Coeliac disease Gastroenteritis Lactose intolerance Post-operative bowel surgery Malabsorption ```

Answer 22

Infancy (common): slow gastric emptying, liquid diet, horizontal posture, lower oesophageal sphincter pressure LOS dysfunction: hiatus hernia Increased gastric pressure: delayed gastric emptying External gastric pressure Gastric hypersecretion: acid Food allergy CNS disorders: cerebral palsy

Answer 23

GI: regurg, non-specific irritability, rumination, oesophagitis, faltering growth Resp: apnoeas, hoarseness, cough, stridor, aspiration, pneumonia, asthma, bronchopulmonary dysplasia Neuro: Sandifer's syndrome --> extension and lateral head turning, dystonic postures

Answer 24

Positioning: nurse infants on head-up slope of 30 ± prone Dietary: feed thickener/small frequent meals, avoid food before sleep, fatty foods, citrus juices, caffeine, carbonated drinks, alcohol, smoking ``` Ranitidine (H2 receptor antagonist) Omeprazole (PPI) Antacids & alginate: gaviscon Domperidone: prokinetic Mucosal protectors: Sucralfate, Corticosteroids ```

Answer 25

Nissen’s fundoplication when medical treatment has failed Indications: oesophageal stricture, barrett’s oesophagus, severe oesophagitis, recurrent apnoea, LRTI, FTT Complications: ‘gas bloating’ syndrome, dysphagia, profuse retching and ‘dumping’ syndrome

Answer 26

``` Oesophageal stricture: dysphagia Barratt's oesophagus: premalignant intestinal metaplasia Faltering growth Anaemia: chronic blood loss Lower respiratory disease ```

Answer 27

Neonates more prone to jaundice due to: Physiological release of haemoglobin from the breakdown of RBC RBC life span of newborn infants is 70 days (compared to 120) Inefficient hepatic bilirubin metabolism Encephalopathy resulting from deposition of unconjugated bilirubin in the basal ganglia and brainstem nuclei Occurs when unconjugated bilirubin levels exceed albumin-binding capacity Neurotoxic effects vary in severity from transient disturbance to severe damage and death

Answer 28

Lethargy and poor feeding Severe = irritability, increased muscle tone, seizures and coma infants who survive may develop choreoathetoid cerebral palsy , learning difficulties and sensorineural deafness

Answer 29

Haemolytic disorders: rhesus/ABO incompatibility, G6PD deficiency, spherocytosis, pyruvate deficiency Congenital infection

Answer 30

``` Physiological jaundice Breast milk jaundice Infection: UTI Haemolysis: G6PD deficiency, ABO incompatibility Bruising Polycythaemia Crigler-Najjar syndrome ```

Answer 31

Unconjugated: physiological or breastmilk jaundice, infection (UTI), hypothyroidism, haemolytic anaemia (G6PD deficiency), high gastrointestinal obstruction (pyloric stenosis) Conjugated (>25􀁐mol/L): bile duct obstruction (choledochal cysts), neonatal hepatitis (toxoplasmosis, rubella, CMV, Hep B&C)

Answer 32

Phototherapy: light (wavelength 450nm) from the blue-green band of the visible spectrum converts unconjugated bilirubin into a harmless water-soluble pigment excreted predominantly in the urine Side-effects: temperature instability, macular rash and bronze discolouration of the skin if bilirubin is conjugated Multiple treatments can be given Exchange transfusion: blood is removed in small aliquots (arterial line or umbilical vein) and replaced with donor blood (peripheral or umbilical vein), twice the infants blood volume is exchanged (2x80ml/kg) Procedure does carry some risk of morbidity or mortality

Answer 33

Stool colour = conjugated bilirubin Pale stool indicative of a reduced conjugated bilirubin content This is most likely due to a biliary tree or post-hepatic obstruction and hence can help locate the problem

Answer 34

Progressive disease due to destruction or absence of the extrahepatic biliary tree and intrahepatic biliary ducts Normal birthweight, but have FTT as the disease progresses, mildly jaundice with pale stool and dark urine, hepatomegaly and splenomegaly are often present

Answer 35

LFTs: little value Fasting USS: demonstrate a contracted or absent gallbladder (may be normal) Radioisotope scan with TIBIDA: shows good uptake in the liver, but no excretion into the bowel Liver biopsy: demonstrates features of extrahepatic biliary obstruction (may overlap with those of neonatal hepatitis) Laparotomy: operative cholangiography fails to outline normal biliary tree

Answer 36

``` Nausea Vomiting Abdominal pain Lethargy Jaundice: 30-50% will not develop Hepatomegaly Splenomegly: 30% Raised LFTs: transaminases ```

Answer 37

RNA virus: faecal-occult transmission May be asymptomatic Majority: mild illness, recover within 2-4 weeks May develop prolonged cholestatic hepatitis (self-limiting) or fulminant hepatitis, but not chronic liver disease No treatment Close contacts given prophylaxis by vaccine

Answer 38

DNA virus :parental transmission (blood, etc) Infants can contract HBV perinatally: asymptomatic, 90% become chronic carriers Older children: asymptomatic/classical features of acute hepatitis Majority resolve spontaneously 1-2% develop fulminant hepatic failure 5-10% become chronic carriers Perinatal transmission: prevented by maternal screening + giving the infant a course of hep B vaccine if indicated Infection may result in chronic HBV liver disease --> may progress to cirrhosis and hepatocellular carcinoma

Answer 39

RNA virus: spread parentally (blood) High prevalence amongst IVDU Haemoglobinopathies/haemophilia = risk factor Vertical transmission: 6%, 2x as common if HIV co-infection Majority become chronic carriers: 20-50% lifetime risk of progression to cirrhosis or HCC Treatment: combination of IFN and ribavirin, not undertaken <4yrs old as may resolve spontaneously

Answer 40

Hep D: defective RNA virus, depends on Hep B for replication --> cirrhosis develops in 50-70% of cases Hep E: RNA virus spread enterally via contaminated water, epidemics occur in some developing countries Non-A to G hep: clinical presentation is similar to Hep A

Answer 41

Usually asymptomatic 40% have hepatitis that may become fulminant <5% are jaundiced

Answer 42

Persistent unexplained abdominal or gastrointestinal symptoms Faltering growth Prolonged fatigue Unexpected weight loss Severe or persistent mouth ulcers Unexplained iron, vitamin B12 or folate deficiency Type 1 diabetes: at diagnosis Autoimmune thyroid disease: at diagnosis Irritable bowel syndrome (only in adults)

Answer 43

Serology: test for total IgA and IgA tTG, as the first choice --> consider using IgG EMA, IgG DGP or IgG tTG if IgA is deficient +ve serological test = referral to paediatric gastroenterologist for further investigation Diagnosis = positive serological result + mucosal changes on jejunal biopsy (increased intraepithelial lymphocytes & a variable degree of villous atrophy and crypt hypertrophy) Followed by resolution of symptoms and catch-up growth upon gluten withdrawal

Answer 44

Dietary information: avoiding gluten (wheat, rye, barley), food labelling, home cross-contamination, How to manage social situations: eating out, travelling, coeliac support groups Annual review: height, weight, review symptoms, diet assessment, dietetic advice May experience anxiety & depression A gluten challenge may be required later in childhood if initial biopsy or response to gluten withdrawal is doubtful, or when the disease presents before the age of 2yrs

Answer 45

Primary: children have failed to ever develop immune tolerance to the relevant food Secondary: usually due to cross-reactivity between proteins present in fresh fruits/vegetables/nuts and those present in pollens --> very common, but leads to mild allergic reaction, such as itchy mouth, but no systemic symptoms Non-IgE: typically occurs hours after ingestion and usually involves the GI tract

Answer 46

FH: food or atopy Past food allergies Other allergies: food or atopy Age: more common in infants & toddlers Asthma: if occur together, both likely to be severe

Answer 47

IgE binds to a high affinity receptor on mast cell --> exposure to the allergen cross-links the bound IgE on sensitized cells and activates --> anaphylactic degranulation = rapid inflammatory response Symptoms: urticaria & itchy skin, facial swelling, wheeze, stridor, abdominal pain & D/V, shock/collapse Management: mild reactions (no cardio/resp symptoms) = anti-histamines, severe reactions = adrenaline IV (Epipen)

Answer 48

Neutrophils bind to innocuous substances --> lytic enzymes released causing tissue damage Symptoms: diarrhoea, abdominal pain, vomiting, colic, failure to thrive Management: avoidance of the relevant food

Answer 49

``` Carbohydrate intolerance: eg. lactose intolerance Protein-energy malnutrition Cystic fibrosis Shwachman-Diamond syndrome Chronic pancreatitis Cholestasis Pernicious anaemia Specific digestive enzyme deficiency: eg. lipase ```

Answer 50

Coeliac disease Short bowel syndrome Dietary protein intolerance: eg. milk protein allergy Intestinal infection or parasites: eg. giardiasis IBD Abetalipoproteinaemia: disorder of lipid metabolism

Answer 51

Immunodeficiency syndromes: eg. HIV Drug reaction: eg. cytotoxics, post-radiation Bacterial overgrowth: eg. pseudo-obstruction

Answer 52

Initial screening: FBC, U&E, creatinine, albumin, total protein, Ca2+, phosphate, LFT, iron status, coeliac antibody screen, coagulation screen, stool MC&S ``` If diagnosis is still unclear consider: Upper GI endoscopy & biopsy: enteropathy Ileocolonscopy if features suggest colitis: ensure clotting is normal prior Sweat test: CF Immune function tests Faecal fat measurement & elastase Faecal alpha-1 anti-trypsin Exocrine pancreatic function tests ```

Answer 53

``` Abdominal pain Diarrhoea, dysentery, flatulence Malabsorption & FTT Abdominal distension Intestinal obstruction Biliary obstruction, liver disease Pancreatitis Fever ```

Answer 54

Giardia lamblia: swallowed cysts develop into trophozoites that attach to the small intestinal villi causing mucosal damage Entamoeba histolytica Cryptosporidium: organism causes a mild self-limiting illness except in immunocompromised patients

Answer 55

40% incidence, in first 4 months of life Support and reassurance the condition is benign Gripe water has no proven benefit Severe/persistent: may be cows milk protein allergy/GORD --> an empirical 2 week trial of a whey hydrolysate formula may be considered Cry-sis helpline for support

Answer 56

>2 discrete episodes in 3m interfering with school and/or usual activities Incidence is 10-15% of school age children No organic cause found in 90% of cases

Answer 57

``` Constipation Dietary indiscretion Food intolerance: lactose/fructose Irritable Bowel Syndrome Psychogenic pain Peptic ulcer Coeliac disease Abdominal migraine: cyclic vomiting syndrome Gallbladder disease Renal colic Dysmenorrhoea UTI Mittleschmerz Abuse: physical or sexual ```

Answer 58

Non-organic disease: thriving, generally well child, short episodes of peri-umbilical pain, good appetite, no other GI symptoms, no FHx of migraine or coeliac disease, normal examination, co-existent symptoms such as headache and fatigue are common Organic disease: likely if presentation is different to above or child <2yrs ‘red flag’ symptoms: weight loss, diarrhoea, blood per rectum, joint symptoms, skin rashes, FHx of IBD or coeliac disease

Answer 59

If organic cause is suspected: FBC, ESR/CRP, U&E, LFT, urine/faecal MC&S and coeliac antibody screening

Answer 60

``` Anorexia, weight loss & lethargy Abdominal cramps Diarrhoea ± blood/mucus, urgency & tenesmus Fever Finger clubbing Anaemia Erythema nodosum, pyoderma gangrenosum Arthritis, ankylosing, spondylitis Eyes: iritis, conjunctivitis, episcleritis Poor growth Delayed puberty Sclerosing cholangitis Renal stones Nutritional deficiencies: vitamin B12 ``` ``` GI signs Aphthous oral ulcers Abdominal tenderness Abdominal distension (UC>CD) RIF mass (CD) Peri-anal disease (CD): abscess, sinus, fistula, skin tags, fissure, stricture ```

Answer 61

Affects whole GI tract: terminal ileum and proximal colon most commonly Non-continuous: ‘skip’ lesions Transmural, focal, subacute or chronic inflammatory disease: initial areas of acutely inflamed, thickened bowel --> strictures and fistulae may develop May be mistaken for psychological problems or anorexia nervosa Diagnosis: based on endoscopic and histological findings on biopsy, presence of non-caseating epithelioid cell granulomata (30% of cases); small bowel imaging may show narrowing, fissuring, mucosal irregularities and bowel wall thickening Remission is induced when normal diet is replaced with whole protein modular feeds (polymeric) for 6-8 weeks: effective in 75% of cases, systemic steroids if not effective Relapse is common and immunosuppressant medication may be required to maintain remission

Answer 62

Recurrent, inflammatory and ulcerating disease involving the mucosa of the colon Rectal is most common or may extend continuously up to involve the entire colon (pancolitis) Terminal ileum may be affected by ‘backwash ileitis’ Presentation: rectal bleeding, diarrhoea and colicky pain, weight loss and growth failure, erythema nodosum, arthritis Diagnosis: endoscopy and histological features after exclusion of infective causes of colitis Histology: mucosal inflammation, crypt damage and ulceration Management: aminosalicylates (ASA) for maintenance and induction, immunomodulatory therapy may be used in more aggressive/extensive cases Severe fulminating disease is a medical emergency: requires IV fluid and steroids

Answer 63

``` Toxic mega colon: UC>CD GI perforation or strictures Pseudopolyps Massive GI haemorrhage Colon carcinoma: UC 50% risk after 10-20yrs Fistula Abscesses: CD ```

Answer 64

Supportive: bowel rest, IV hydration and PN Drug treatment: mesalazine (ASA), corticosteroid enemas, oral prednisolone or IV methylprednisolone Abx: ciprofloxacin, metronidazole Maintenance treatment: immunomodifiers (Azathrioprine, Ciclosporin, Tacrolimus or Methotrexate) or Infliximab (anti-TNF) Dietary treatment: polymeric/elemental diets are useful to induce remission (CD>UC), high relapse rate, dietary supplementation is often required Surgical treatment: UC: total colectomy & ileostomy, later pouch creation and anal anastomosis CD: local surgical resection for severe localised disease

Answer 65

``` H.pylori infection Stress ulcer: post-trauma, Hypoxic-ischaemic encephalopathy Drug related: NSAIDs Increased acid secretion: Zollinger-Ellison syndrome, multiple endocrine neoplasia type I, hyperparathyroidism Crohn’s disease Eosinophilic gastroenteritis Hypertrophic gastritis Autoimmune gastritis ```

Answer 66

``` Often asymptomatic Chronic abdominal and epigastric pain Nausea ± vomiting GI haemorrhage FFT ± anorexia Iron deficiency anaemia Peforation (rare) Indigestion, bloating, hiccups and loss of appetite ``` Peptic ulcer: burning in the abdomen, below the ribs and above umbilicus, pain reduced by eating, drinking milk, antacids Bleeding ulcers: haematemesis or melena

Answer 67

Mimics acute appendicitis Fever, malaise Non-specific central abdominal pain which resolves in 24-48hrs, pain is less severe than appendicitis, and tenderness if RIF is variable, accompanied by URTI with cervical lymphadenopathy

Gastroenterology Flashcards

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