Gastroenterology

Question 1

Why are infants more prone to GORD

Answer 1

Immature involuntary relaxation of the lower oesophageal sphincter
lying on back
Liquid diet

Question 2

What are the clinical signs of GORD

Answer 2

distress post feeding
vomiting and posseting
poor weight gain

Question 3

What are the complications of GORD

Answer 3

	due to regurgitation and sequelae:
	poor weight gain
	nausea, vomiting
	due to oesophagitis and sequelae:
	chest/ epigastric pain
	irritability/ feeding problems
	anaemia/ haematemesis
	dysphagia/ peptic stricture causing obstruction
	Respiratory symptoms:	
	aspiration pneumonia (recurrent or chronic)
	bronchospasm/ wheezing (intractable asthma)
	apnoea/ cyanotic episodes/ ALTEs
	cough/ stridor/ hoarseness/ hiccoughs
	Neurobehavioural:
	Infant “spells” (including seizure-like events)
	Sandifer’s syndrome`

Question 4

What investigations could you do for GORD

Answer 4

Mainly clinical diagnosis
24 hour oesophageal pH monitoring
barium studies
endoscopy

Question 5

How would you treat GORD

Answer 5

reassure that 95% will go by the age of 18 months 
prescribe thickners (gaviscon and thick and easy) for feeds, H2 antagonists/PPIs
prokinetic drugs like domperidone
surgery may be required - Nissen fundoplication

Question 6

What is pyloric stenosis

Answer 6

thickening of the pyloric muscle causing gastric outlet obstruction. presents between 2-7 weeks

Question 7

What are the clinical features of pyloric stenosis

Answer 7

Non bilious Vomiting, which increases in frequency and
forcefulness over time, ultimately becoming
projectile
• Hunger after vomiting until dehydration leads to
loss of interest in feeding
• Weight loss if presentation is delayed.

Question 8

What is the classic metabolic sign of pyloric stenosis

Answer 8

Hypochloraemic hypokalaemic metabolic alkalosis. This is due to loss of acidic gastric acid contents and the kidneys retaining hydrogen ions at the expense of potassium

Question 9

How would you diagnose pyloric stenosis

Answer 9

Test feed with milk - look for gastric peristalsis, look for pyloric mass that looks like an olive in RUQ.
abdominal USS if in doubt.
Check U&Es for hypercholraemic metabolic alkalosis

Question 10

how do you treat pyloric stenosis

Answer 10

correct fluid balance and electrolyte disturbance.

Ramstedt pyloromyotomy surgical procedure

Question 11

What are the causes of gastroenteritis

Answer 11

rotavirus - most common
noravirus
astrovirus

Shigella
e.coli
campylobacter jejuni
cholera - vibro cholerae 
typhoid - salmonella typhi

Question 12

What are non infective cause of diarrhorea

Answer 12

pyloric stenosis
intussusception
acute appendicitis 
necrotising enterocolitis
short gut syndrome
hirschsprung disease 
diabetic ketoacidosis

Question 13

clinical signs of gastroenteritis

Answer 13

Sudden change to loose watery stool and vomiting.
other members of family may have had similar
dehydration
bloody stool
usually preceeded by a viral illness
abdominal pain
fever indicates bacterial cause

Question 14

What investigations would you perform for gastroenteritis

Answer 14

U&Es, plasma urea, glucose, electrolytes

stool culture if stool is bloody or child is septic or immunocompromised.

Question 15

How would you manage gastroenteritis

Answer 15

Oral rehydration therapy/ fluids

antibiotics if bacterial

NO LOPERAMIDE

Question 16

What is constipation

Answer 16

less than 1 stool a day in infants

and less than 3 stools a day in school children

Question 17

Causes of constipation

Answer 17

hirschsprungs disease
hypothyroidism
coeliac disease
spina bifida 
abnormal anorectal anatomy
sexual abuse
toilet training 
stress
diet
perianal crohns disease 
hypercalcaemia
dehydration

Question 18

clinical features of constipation

Answer 18

pain
distended abdomen
overflow diarrhoea
pr bleeding
anorexia
fear of toilet
straining
loss of the feeling the need to defecate - often before overflow diarrhoea

Question 19

Management of constipation

Answer 19

1. diet and habit change
2. Macrogol laxative (type of osmotic laxative) - e.g. movicol (polyethene glycol)
3. stimulant laxative - senna +/- lactulose
4. enema or manual evacutation

polyethene glycol for maintenance

Question 20

What is appendicitis

Answer 20

inflammation from the appendix usually following obstruction (faecolith)

Question 21

How to Dx appendicitis

Answer 21

abdominal USS
FBC and CRP
X ray
pregnancy test

Question 22

Treatment of appendicitis

Answer 22

appendectomy

IV antibiotics

Question 23

How would you treat an inguinal hernia

Answer 23

opioid analgesia and gentle compression - then referral to surgery

BUT if nonreducible then emergency referral to surgery due to risk of strangulation

Question 24

How would you manage a crohns flare in children

Answer 24

Remission is induced with nutritional therapy, when
the normal diet is replaced by whole protein modular
feeds (polymeric diet) for 6–8 weeks. This is effective
in 75% of cases. Systemic steroids are required if
ineffective.

budesonide
azathioprine
then biologics 
long term enteral nutrition
surgery

Question 25

Definition of failure to thrive

Answer 25

failure to gain adequate weight or achieve adequate growth during infancy or early childhood’ • Fall across 2 centiles on growth chart

Question 26

What is marasmus

Answer 26

Undernutrition plus discrepancy between height and weight (more than 3 SD below the median). Caused by lack of all nutrition. standard deviations below the median, Oedema is not present. Skinfold thickness and mid-arm circumference are markedly reduced, and affected children are often withdrawn and apathetic. corresponding to <70% weight for height, and a wasted, wizened appearance.

Question 27

What is kwashiorkor

Answer 27

Another manifestation of severe protein malnutrition, not necessarily lack of overall nutrition. There is generalised oedema as well as severe wasting. Because of the oedema, the weight may not be as severely reduced. In addition, there may be: • a ‘flaky-paint’ skin rash with hyperkeratosis (thickened skin) and desquamation • a distended abdomen and enlarged liver (usually due to fatty infiltration) • angular stomatitis • hair which is sparse and depigmented • diarrhoea, hypothermia, bradycardia and hypotension

Question 28

What is hirschsprungs disease

Answer 28

Absence of ganglion cells in the myenteric and submucosal plexuses in part of the large bowel

Question 29

Risk factors for hirschsprung disease

Answer 29

downs syndrome meconium ileus male family history

Question 30

Clinical features of hirschsprung disease

Answer 30

usually intestinal obstruction in the newborn period following delay in passing meconium. In later childhood – profound chronic constipation, abdominal distension and growth failure

Question 31

Diagnosis and management of hirschsprung disease

Answer 31

barium enema and Xray showing contracted narrow section of bowel Suction rectal biopsy treatment - colostomy then anastomosing normally innervated bowel

Question 32

What is intersussception

Answer 32

telescoping of the bowel

Question 33

How does intussusception present

Answer 33

paroxysmal, colicky pain, legs drawn up with pallor, sausage shaped abdominal mass, redcurrant jelly stool

Question 34

How is intussusception diagnosed

Answer 34

abdominal USS Abdominal x ray

Question 35

How is intussusception treated

Answer 35

Reduction is attempted by rectal air insufflation unless peritonitis is present • Surgery is required if reduction with air is unsuccessful or for peritonitis.

Question 36

What is meckel diverticulum

Answer 36

An ileal remnant of the vitello-intestinal duct, a Meckel diverticulum, which contains ectopic gastric mucosa or pancreatic tissue.

Question 37

How does meckel diverticulum present

Answer 37

Generally asymptomatic, but may present with bleeding (which may be life-threatening), intussusception, volvulus or diverticulitis.

Question 38

How do you diagnose meckel diverticulum

Answer 38

A technetium scan will demonstrate increased uptake by | ectopic gastric mucosa in 70% of cases

Question 39

How do you treat meckel diverticulum

Answer 39

surgical resection

Question 40

What is infant colic

Answer 40

Paroxysmal, inconsolable crying or screaming often accompanied by drawing up of the knees and passage of excessive flatus takes place several times a day, particularly in the evening. Occurs <4 months

Question 41

How is infant colic managed

Answer 41

The condition is benign but it is very frustrating and worrying for parents and may precipitate non-accidental injury in infants already at risk. Support and reassurance should be given. If severe and persistent, it may be due to a cow’s milk protein allergy or gastro-oesophageal reflux and an empirical 2-week trial of a whey hydrolysate formula followed by a trial of anti-reflux treatment may be considered.

Question 42

What is the most appropriate way to confirm a diagnosis of pyloric stenosis

Answer 42

test feed. NG tube and aspiration to empty the stomach, small feed of dioralyte, examiners fingers placed just below the liver edge. palpable olive mass = stenosed pylorus

Question 43

What would indicate cows milk intolerance

Answer 43

abdominal pain chronic vomiting eczema flatulence, bloody stool, diarrhoea/constipation

Question 44

What investigations are needed for cows milk intolerance

Answer 44

skin prick or specific IgE antibody testing

Question 45

How is cows milk intolerance managed

Answer 45

cows milk elimination diet, hypoallogenic infant formula, mother to avoid cows milk