Gastroenterology Flashcards
(126 cards)
1
Q
What are the medical causes of abdominal pain in over 5 years old?
A
Constipation is very common UTI Coealic IBD IBS Mesenteric Adenitis Abdominal migraine Pyelonephritis Henoch schonlein purpura Tonsilitis DKA Infantile colic
Additional causes in adolescent girls: ovarian, Dysmenorrhoea, PID, ovarian torsion, pregnancy, ectopic pregnancy.
2
Q
What are the surgical causes of abdominal pain in children?
A
Appendicitis
Intusussception
Bowel obstruction
Testicular torsion
3
Q
What are the red flags for serious abdominal pain?
A
Persistent or bilious vomiting Severe chronic diarrhoea Fever Rectal bleeding Weight loss or faltering growth Dysphagia Nighttime pain Abdominal tenderness
4
Q
What does raised faecal calprotectin indicate?
A
IBD
5
Q
When is recurrent abdominal pain diagnosed?
A
When a child is experiencing repeated episodes of abdominal pain with no underlying condition.
6
Q
How does abdominal migraine present?
A
Central abdominal pain which lasts for more than 1 hour. Examination is normal There maybe associated: N and V Anorexia Pallor Headache Photophobia Aura
7
Q
What are the management options for treating the acute attack of a migraine?
A
Low stimulus environment (quiet, dark room)
Paracetamol
Ibruprofen
Sumatriptan
8
Q
What are the preventative meds used for abdominal migraine?
A
Pizotifen (serotonin agonist, most important to remember)
Propranolol
Cryptoheptadine (antihistamine )
Flunarazine (CCB)
9
Q
Why is it important to stop pizotifen slowly?
A
It is associated with withdrawal symptoms- depression, anxiety, poor sleep, tremor.
10
Q
What is encopresis?
A
This is the term for faecal incontinence, which is no considered pathological until 4 years of age. It is a sign of chronic constipation where the rectum becomes stretched and looses sensation.
Large hard stools remain in the rectum and only loose stools are able to bypass the blockage and leak out.
11
Q
Name some rare causes of encopresis…
A
Spina bifida Hirschprings disease Cerebral palsy Learning difficulty Psychosocial stress Abuse
12
Q
What are the lifestyle factors which can lead to the development and continuation of constipation?
A
Sedentary lifestyle
Lack of fibre in diet
Poor fluid intake/dehydration
Psychosocial problems
13
Q
What is desensitisation of the rectum?
A
This is where patients develop a habit of not opening their bowels when they need to and ignoring the sensation of a full rectum. Over time they lose the sensation of needing to open their bowels and open their bowels even less frequently. They start to retain faeces in their rectum which leads to faecal impaction, over time the rectum stretches as it fills with more and more faeces which leads to further desensitisation of the rectum. The longer this goes on, the more difficult it is to treat the constipation and reverse the problem.
14
Q
What are the secondary causes of constipation?
A
Cystic fibrosis Hypothyroidism Spinal cord lesions Hirschsprung’s disease Sexual abuse Intestinal obstruction Anal stenosis Cows milk intolerance.
15
Q
What are the red flags for constipation?
A
Not passing meconium within 48 hrs of birth (indicates cystic fibrosis or Hirschsprung’s disease)
Neurological signs or symptoms, particularly in the lower limbs as this can indicate cerebral palsy or a spinal cord lesion.
Vomiting (intestinal obstruction or Hirschsprung’s disease)
Ribbon stool (anal stenosis)
Abnormal anus (indicates sexual abuse, anal stenosis, IBD)
Abnormal lower back or buttocks (spina bifida, spinal cord lesion or sacral AGENESIS)
Failure to thrive (coeliac or hypothyroidism)
Acute severe abdominal pain and bloating
16
Q
What are the complications of constipation?
A
Pain Reduced sensation Anal fissures Haemorrhoids Overflow and soiling Psychosocial morbidity
17
Q
What is the management of constipation?
A
Correct any reversible contributing factors, recommend a high fibre diet and good hydration Start laxative (Movicol is first line) Faecal impaction may require a disimpaction regime with high doses of laxatives at first Encourage and praise visiting the toilet, this could involve scheduling visits, bowel diary and star charts.
Laxatives should be continued long term and slowly weaned off as the child develops a normal, regular bowel habit.
18
Q
What is Gastro oesophageal reflux?
A
Where the contents of the stomach reflexes through the lower oesophageal sphincter, oesophagus, throat and mouth. This is quite Normal for babies and most babies will stop having it by 1 year.
19
Q
It is normal to have reflux after larger feeds in babies, what are the signs of problematic reflux?
A
Chronic cough Hoarse cry Distress, crying or unsettled after feeding Reluctance to feed Pneumonia Poor weight gain
Children over one year May experience similar symptoms to adults- heartburn, acid regurgitation, retrosternal or epigastric pain, bloating and nocturnal cough.
20
Q
What are the possible causes of vomiting in babies?
A
Over feeding GORD Pyloric stenosis Gastritis or gastroenteritis Appendicitis Infections- UTI, tonsilitis, meningitis Intestinal obstruction Bulimia.
21
Q
What could not keeping any food down or projectile vomiting be a sign off?
A
Pyloric stenosis or intestinal obstruction
22
Q
What is bile stained vomit a sign off?
A
Intestinal obstruction
23
Q
What is haematemesis or Malaena a sign of?
A
Peptic ulcer
Oesophagitis
Varices
24
Q
What does the red flag reduced consciousness, bulging fontanelle and reflux indicate?
A
Meningitis or raised ICP.
25
What does reflux and blood in the stools indicate?
Gastroenteritis
| Cows milk allergy
26
What is the management of reflux?
Small frequent meals
Burping regularly to help milk settle
Not over feeding
Keep baby upright after feeding (not lying flat)
More problematic cases...
. Gaviscon mixed with feeds
. Thickened milk or formula
. Omeprazole
Very rare cases: investigation with barium meal and surgical fundoplication
27
What is the pyloric sphincter?
A ring of smooth muscle that forms the canal between the stomach and the duodenum.
28
What is the pathophysiology behind projectile vomiting in pyloric stenosis?
When the pyloric sphincter is hypertrophied it is narrowed and prevents food going from the stomach into the duodenum as normal. After feeding there is powerful peristalsis from the stomach to try and get food into the duodenum, this peristalsis becomes so powerful that it ejects the food into the oesophagus, out the mouth and across the room.
29
What are the features of pyloric stenosis?
A hungry baby that is think pale, failing to thrive
Projectile vomiting
When examined after feeding, the peristalsis can be seen by observing the abdomen
Mass ‘large olive’ in upper abdomen from the hypertrophic pylorus muscle
Blood gas analysis will show a hypochloric (low chloride%) metabolic alkalosis as the baby is vomiting the hydrochloric acid from the stomach.
30
What is the diagnosis of pyloric stenosis?
Abdominal ultrasound which visualises the thickened pylorus.
31
What is the treatment of pyloric stenosis?
Laparoscopic pyloromyotomy
Also known as Ramstedts operation
Prognosis is excellent following the operation
32
What is gastritis?
Inflammation of the stomach lining.
33
What is enteritis?
Inflammation of the intestines
34
What is gastroenteritis?
Inflammation all the way from the stomach to the intestines
| Presents with N+V, diarrhoea
35
What are the differentials for loose stool in infants?
```
Infections (gastroenteritis)
IBD
Lactose intolerance
Coeliac disease
Cystic fibrosis
Toddlers diarrhoea
Irritable bowel syndrome
Medications (ABx)
```
36
What are the viral causes of gastroenteritis?(60%)
Rotavirus, norovirus, adenovirus (less common and more subacute diarrhoea)
37
E. coli is a normal intestinal bacteria, with only certain strains causing gastroenteritis, how is it spread?
Infected faeces
Unwashed salads
Contaminated water
38
E. coli 0157 produces the shiga toxin, what does this cause?
Bloody diarrhoea
Abdo cramps
Vomiting
Haemolytic uraemic syndrome
39
What is haemolytic uraemic syndrome and what increases the risk of getting it when suffering from E. coli?
It is a triad of: AKI, haemolysis and thrombocytopenia
| It is at increased risk when the patient is taking ABX
40
What is a common cause of travellers diarrhoea?
Campylobacter jejuni
41
What is the gram stain of campylobacter jejunum?
campylobacter jejunum means curved bacteria and it is a gram negative bacteria.
42
What is campylobacter jejuni spread by?
Raw or improperly cooked poultry
Untreated water
Unpasteurised milk
43
What are the symptoms of campylobacter jejuni?
Abdominal cramps
BLOODY diarrhoea
Vomiting
Fever
44
Would you give antibiotics in campylobacter jejuni?
Yes you can give if severe symptoms or the patient has other risk factors (HIV or heart failure)
45
What ABx would be given to a patient with campylobacter jejuni?
Popular choices are azithromycin or ciprofloxacin
46
What is the intubation period for campylobacter jejuni?
2 to 5 days and symptoms resolve after 3 to 6 days
47
How is shigella spread?
Spread by faeces contaminated water, drinking water or food.
48
What does shigella present with?
BLOODY diarrhoea
Abdominal cramps
Fever
49
How would you treat shigella?
Azithromycin or ciprofloxacin
50
How is salmonella spread?
Eating raw poultry
Raw eggs
Food contaminated with infected faeces of small animals
51
How does salmonella present?
Watery diarrhoea which is associated with mucus or blood, abdominal pain and vomiting.
52
What is the gram stain of bacillus cereus?
Gram positive rod
53
How is bacillus cereus spread?
Gram positive rod which is spread through inadequately cooked food, it grows well on food not immediately refrigerated after cooking.
Typical food= fried rice
54
What is coeliac disease?
Autoimmune condition where exposure to gluten causes an immune reaction that creates inflammation in the small intestine, it usually develops in early childhood but can start at any age.
55
What happens in coeliac disease when a person is exposed to gluten?
Autoantibodies are created- the main ones to remember are anti tissue transglutaminase (anti TTG) and anti Endomysial (anti EMA). These antibodies correlate to disease activity and will rise with more active disease and may disappear with effective treatment.
56
What structure does coeliac disease particularly affect?
Inflammation affects the small bowel, particularly the jejunum And causes atrophy of the intestinal Villi. Intestinal villi helps with absorbing nutrients from food passing through the intestines and therefore coeliac causes malabsorption of nutrients
57
What should you also test every patient for in patients who have coeliac disease?
Type 1 diabetes! The conditions are often linked.
58
How does coeliac disease present?
Often asymptomatic so have low threshold for treating
Fatigue
Failure to thrive
Diarrhoea
Weight loss
Mouth ulcers
Anaemia secondary to iron, B12 or folate deficiency
Dermatitis herpetiformis (itchy blistering skin rash that typically appears on the abdomen).
Rarely it can present with neurological symptoms,,.
Peripheral neuropathy, cerebellar ataxia, epilepsy
59
What are the genetic associations with coeliac disease?
HLA DQ2 gene (90%)
| HLA DQ8
60
What autoantibodies do you test for in coeliac?
Anti tissue transglutaminase antibodies (anti TTG)
Endomysial antibodies (EMAs)
Deaminated gliadin peptide antibodies (anti DGPs)
You must also test for total immunoglobulin A levels (anti TTG and anti EMA are immunoglobulin As)
61
How do you diagnose coeliac disease?
Make sure person is on a gluten diet
Test for total immunoglobulin A levels
Anti EMA
Anti TTG
Endoscopy and intestinal biopsy- this will show crypt hypertrophy and villus atrophy
62
What conditions is coeliac disease associated with?
```
Type 1 diabetes
Thyroid disease
Autoimmune hepatitis
Primary biliary cirrhosis
Primary sclerosing cholangitis
Down’s syndrome
```
63
What are the complications of untreated coeliac disease?
```
Vitamin deficiency
Anaemia
Osteoporosis
Ulcerative jejuni this
Non Hodgkin lymphoma
Small bowel adenocarcinoma (rare)
Enteropathy associated T cell lymphoma of the intestine
```
64
What would the presentation of IBD be?
```
Abdominal pain
Perfuse diarrhoea
Bleeding
Weight loss
Anaemia
May be systematically unwell during flares with fever, malaise, dehydration
```
65
What are the extra intestinal manifestations of IBD?
```
Finger clubbing
Erythema no dorsum
Pyoderma gangrenosum
Episcleritis and iritis
Inflammatory arthritis
Primary sclerosing cholangitis (ulcerative colitis)
```
66
What investigations would you do for IBD?
FBC to check for anaemia
CRP
Faecal calprotectin
Endoscopy (OGD and colonoscopy) with biopsy is the gold standard investigation in the diagnosis of IBD.
Imaging with CT, MRI and ultrasound can be used to look for complications- fistula, stricture, abscess.
67
What is the management for inducing remission in Crohns?
First line are steroids (oral prednisolone/ IV hydrocortisone)
Enteral nutrition can be used as an alternative to steroids where there are concerns about growth or SE
If steroids alone don’t work then you can consider adding immunosuppressant medication under specialist guidance- azathrioprine, mercaptopurine, methotrexate, infliximab, adalimumab.
68
What medications are used to maintain remission in crohns?
Azathrioprine
Mercaptopurine
Surgery can only be used if the disease only affects the distal ileum but crohns typically involves the entire GI tract.
69
How do you induce remission in ulcerative colitis?
First line= aminosalicylate (mesalazine oral or rectal)
| Second line= corticosteroids (prednisolone)
70
How do you maintain remission in UC?
Aminosalicylate
Azathioprine
Mercaptopurine
71
Maintaining remission in UC can also involve surgery, what surgery could you use?
Removing the colon and rectum (panproctocolectomy).
| Patient is either left with a permanent ileostomy or ileo anal anastomosis (J pouch).
72
What is biliary atresia?
Congenital condition where a section of the bile duct is either absent or narrowed, this results in cholestasis, where the bile can’t be transported from the liver to the bowel, conjugated bilirubin is usually excreted in the bile therefore biliary atresia prevents the excretion of conjugated bilirubin.
73
How does biliary atresia present?
Presents shortly after birth with significant jaundice. Should suspect biliary atresia in premature babies that have had jaundice for 21 days and 14 days in term babies.
74
How can you diagnose biliary atresia?
Testing the conjugated and unconjugated bilirubin levels. Conjugated bilirubin suggests the liver is processing the bilirubin for excretion but is not able to excrete the conjugated bilirubin as it can’t flow through the biliary duct into the bowel.
75
How do you manage biliary atresia?
It is managed with the Kasai portoenterostomy which involves attaching a section of the intestine to the opening of the liver where the duct normally attaches.
Often patients need a liver transplant.
76
What are the causes of intestinal obstruction in kids?
```
Meconium Ileus
Hirschsprung’s disease
Oesophageal atresia
Duodenal aresia
Intusussception
Imperforate anus
Malrotation of intestines with a volvulus
Strangulated hernia
```
77
How would a child with intestinal obstruction present?
```
Persistent vomiting (May be bilious and contains bright green bile)
Abdo pain and distension
Failure to pass stools or wind
Abnormal bowel sounds- high pitched and twinkling early in the obstruction and absent later.
```
78
How do you diagnose intestinal obstruction in children?
Initial investigation of choice is an abdominal X-ray- shoes dilated loops of bowel proximal and collapsed loops distally. Also there will be an absence of air in the rectum.
79
What is the management of intestinal obstruction in children?
Refer to paediatric surgical unit as an emergency.
| Make NBM, give IV fluids and insert a nasogastric tube.
80
What is Hirschsprung’s disease?
A congenital condition where nerve cells of the myenteric plexus are absent in the distal bowel and rectum.
81
What is the pathophysiology in Hirschsprung’s disease?
Absence of parasympathetic ganglion cells, during fetal development these cells start higher in the GO tract and gradually migrate down to the distal colon and rectum. In Hirschsprung’s the parasympathetic ganglion cells don’t travel all the way down to the colon and a section of the colon at the end is left without the parasympathetic ganglion cells.
82
In Hirschsprung’s disease the length of colon without innervation varies between patients from a small area to the entire colon. What is it called when the whole colon is affected?
Total colonic aganglionosis
83
Hirschsprung’s disease usually occurs in isolation, however it is associated with a number of other conditions. What other conditions is it associated with?
Down’s syndrome
Neurofibromatoses
Waardenburg syndrome
Multiple endocrine neoplasia type 2
84
What is intusussception?
This is a condition where the bowel invaginate or telescopes into itself, this thickens the overall size of the bowel and narrows the Lumen at the folded area leading to a palpable mass in the abdomen and obstruction to the passage of faeces through the bowl. It typically occurs in infants 6 months to 2 years and is more common in boys.
85
How does intusussception present?
```
Severe colicky abdo pain
Pale, lethargic and unwell child
RUQ mass on palpation
Vomiting
Intestinal obstruction
```
86
What will the typical presentation of intussusception be on exams?
Redcurrent jelly stool
Sausage shaped mass in abdomen
Child will have had a viral URTI and will have features of intestinal obstruction.
87
How do diagnoses intussusception?
Ultrasound scan or contrast enema
88
How do you manage intusussception?
Therapeutic enemas
Surgical reduction if enemas don’t work
If bowel becomes gangrenous (due to disruption of blood supply) or bowel is perforated then surgical resection is required.
89
What are the complications of intussusception?
Gangrenous bowel
Obstruction
Perforation
Death
90
What is appendicitis?
Inflammation of the appendix (a small thin tube sprouting from the caecum), the appendix becomes inflammed due to infection trapped in the appendix.
91
What are the signs and symptoms of appendicitis?
```
Key presenting feature is abdominal pain, typical starting centrally and then moving to the right iliac fossa.
Tenderness at the McBurney’s point
N + V
Rosvings and psoas
Lack of appetite
Anorexia
Rebound tenderness
Percussion tenderness
Guarding
```
(Rebound tenderness and percussion tenderness suggest peritonitis)
92
How do you diagnose appendicitis?
Usually clinically and CRP
Ultrasound scan is useful for females to exclude ovarian and gynaecological pathology
A diagnostic laparoscopy can be used in cases where nothing is shown from investigations but clinically you are expecting appendicitis.
93
What are the key differentials for appendicitis?
Ectopic pregnancy
Ovarian cysts
Meckles diverticulum
Mesenteric adenitis
94
How is appendicitis in children managed?
Older children (those above ten years old) can be managed at local hospitals by general surgical teams. Younger children need to be admitted under paediatric surgeons.
Removal of inflammed appendix (appendicectomy) is the definitive management for acute appendicitis. Laparoscopic surgery is associated with fewer risks and faster recovery compared to open surgery (laparotomy).
95
What are the complications of appendicectomy?
```
Bleeding, infection, pain, scars
Damage to bowel, bladder, other organs
Removal of a normal appendix
Anaesthetic risks
VTE (DVT or PE)
```
96
What is the usual clinical presentation of Hirschsprung’s?
Delayed passage of meconium with distension of the abdomen.
97
What is necrotising enterocolitis?
Inflammation of the bowel (intestines) which damage the bowel to a variable extent. Usually causes a temporary intolerance of milk feeds but at its worse the bowel may be so damaged that part of it actually dies.
98
What is most commonly affected in necrotising enterocolitis?
Mesenteric ischaemia causes bacterial invasion of the mucosa leading to sepsis. Terminal ileum, caecum and distal colon are the most commonly affected.
99
When would meconium ileus present?
Meconium ileus is distal small bowel obstruction secondary to abnormal bulky and viscid meconium. Ninety percent of the infants have cystic fibrosis and the abnormal meconium is the result of deficient intestinal secretion. It presents in the first few days of life.
100
How does meconium ileus present?
Presents during the first few days of life with gross abdominal distension and bilious vomiting.
101
What would x Ray of abdomen on a patient with meconium ileus show?
Distended coulda of bowel and typical mottled ground glass appearance.
102
When does pyloric stenosis normally present?
2-4 weeks of life.
103
What is pyloric stenosis caused by?
Hypertrophy of the circular muscles of the pylorus
104
What are the features of pyloric stenosis?
Projectile vomiting, this typically occurs 30 minutes after a feed
Constipation and dehydration
Palpable mass present in upper abdomen
Hypochloraemic, hypokalaemia alkalosis due to persistent vomiting.
105
How do you manage pyloric stenosis?
Ramstedt’s pyloromyotomy
106
What would you feed babies who are 0-6 months?
Should be fed entirely on milk, ideally breast but formula is acceptable.
If you need water for formula then you need to boil it first before cooling
NO COWS MILK
107
How do you feed children who are 6 months?
Continue with breast or formula milk
Cows milk still shouldn’t be given as a drink, however it can be mixed with food
Water no longer needs to be boiled
You can now introduce cups for drinking
Weaning should be gin (weaning is the introduction of solids into the diet, initially mashed or soft cooked.
Firmer foods can be introduced when the child becomes more confident and better able to co ordinate chewing and swallowing,
108
What changes in terms of feeding at 9 months?
Should continue with breast or formula milk but at a reduced amount and with reduced time on breast/bottle.
In terms of solid food, baby should not be eating 3 meals per day.
109
What should you change in terms of feeding at 12 months?
Milk: continue with breast milk if required but now replace formula with cows milk
Cows milk may be taken as a drink, but should be full fat and from a cup.
Water from the tap and drunk from a cup
3 meals per day- solid
110
What would overfeeding present like?
Overfeeding is considered in children who are fed more than 200ml/kg/ day and they will present with positing or vomiting without any other symptoms.
111
What are the bacterial causes of gastroenteritis?
Salmonella spp
Campylobacter spp
Shigella spp
E. coli 0157:H7
112
What are the risk factors for gastroenteritis?
```
Age <5
Poor hygiene
Poverty
Contact with infected children
Daycare attendance
Winter months
Lack of breastfeeding
```
113
Normally gastroenteritis presents with non bloody diarrhoea, what causes of gastroenteritis May cause bloody diarrhoea?
. Campylobacter spp
. Salmonella spp
. Shigella spp
. E. coli 0157: H7
114
How would you manage gastroenteritis?
Encourage the mother to continue breastfeeding/formula feeding as normal and push oral fluids (if >6months). ABx and anti diarrhoea are not routinely prescribed.
Add an antiemetic if vomiting is prominent (typically on danseur on)
Fluid management dependent on hydration status
115
What advice should you give to parents regarding treating gastroenteritis at home?
Need to provide a safety net on how to spot the red flag symptoms for dehydration and shock
Children can usually be safely managed at home and symptoms tend to improve within 5-7 days
Encourage plenty of fluids (ORS if required) and avoid fruit and carbonated drinks
Reintroduce the child’s normal diet as soon as they can tolerate it.
Contact a healthcare professional if dehydration or symptoms not resolving.
116
What are the risk factors for Gastro oesophageal reflux?
Obesity
Increased intra gastric pressure (pyloric stenosis and other causes of outflow obstruction)
Neurodevelopmental abnormalities- cerebral palsy and Down syndrome
Oesophageal abnormalities- hiatal herniae
117
What are the symptoms and signs of Gastro oesophageal reflux?
Symptoms
Regurgitation of effortless vomiting which typically occurs post prandially
Abdominal pain post prandially- if left this may manifest as feeding difficulties and failure to thrive
If complications are present, oesophagitis may present a haematemesis or dysphagia
Torticollis or osipthotonus
118
What are the investigations to diagnose Gastro oesophageal reflex?
Usually just a clinical diagnosis
| If the diagnosis is unclear a 24 hour oesophageal pH study can be done, barium meal, endoscopy
119
What are the differential diagnosis of Gastro oesophageal reflux?
```
Overfeeding gastritis, gastroenteritis
Food allergy- cows milk protein
Hiatal herniae
Pyloric stenosis
Malrotation
Meningitis
UTI
```
120
What are the non pharmacological management options for Gastro oesophageal reflux?
Non pharmacological- reassure parents that this is a common condition which resolves with age
Parents should avoid overfeeding (try reducing the volume of feeds but increase their frequency), encourage upright position and properly wind the infant.
121
What are the pharmacological managements of Gastro oesophageal reflux?
Gaviscon infant can initially be given
Omeprazole: PPIs are generally last line management
Ranitidine: H2RAs May be beneficial
122
Why are PPIs generally last line management in Gastro oesophageal reflux?
They can increase the risk of gastroenteritis, community acquired pneumonia and necrotising enterocolitis.
123
What surgical management can be offered to a child who has life threatening complications of the disease?
Nissens fundoplication.
124
How should you advise a parent to wind their child if they swallow air along with the milk?
On their chest with child’s chin resting on parents shoulder
Sitting sideways on their lap
Face down on their lap
125
What is infantile colic?
Benign condition without any known underlying medical or surgical cause. It typically begins in the first few weeks of life and resolves spontaneously by 4-5 months of age.
It is characterised by paroxysmal crying:
. That lasts more than 3 hours per episode, on more than 3 days of the week for more than 3 weeks .
126
What does ribbon stool indicate?
Anal stenosis
