Gastroenterology Lecture

Question 1

Differentials for vomitting after feeds

Answer 1

• GORD (if more than 4 months) otherwise GOR
• Cows milk protein intolerance
• Can be normal posseting +/- overfeeding (sphincter not strong)

Question 2

Management of vomitting after feeds

Answer 2

• Observe feeds, get health visitor involved
• Trial of GOR advice - technique of bupring, smaller feeds, keeping upright after feeding
• Trial of CMP free
• GOR meds - eg PPI, milk thickener, gaviscon

Question 3

Management of functional constipation

Answer 3

• Dietary advice inc fibre advice
• Good fluid intake
• Exercise
• Toilet training with encourgagement system (eg rewards)

Meds:
* Disimpaction regime (higher doses laxatives) - from home unless obstructive features
* Then maintenance regime
* Macrogol (osmotic laxatives) first line (eg Movicol), stimulant 2nd line

Question 4

Red flags for constipation in children

Answer 4

• Not passing meconium within 48 hours of birth (cystic fibrosis or Hirschsprung’s disease)
• Neurological signs or symptoms, particularly in the lower limbs (cerebral palsy or spinal cord lesion)
• Vomiting (intestinal obstruction or Hirschsprung’s disease)
• Ribbon stool (anal stenosis)
• Abnormal anus (infection, stenosis, inflammatory bowel disease or sexual abuse)
• Abnormal lower back or buttocks (spina bifida, spinal cord lesion or sacral agenesis)
• Failure to thrive (coeliac disease, hypothyroidism, cystic fibrosis or safeguarding issues)
• Acute severe abdominal pain and bloating (obstruction or intussusception)

Question 5

3 important underlying causes of constipation in children

Answer 5

• Hirschprungs
• Spina bifida
• Cerebral palsy

Question 6

How to test for Hirchsprungs

Answer 6

Rectal biopsy

Question 7

Differentials for abdominal pain, failure to gain weight, pale loose stools

Answer 7

• Coeliac disease
• IBD
• Cystic fibrosis
• Overflow diarrhoea
• Poor diet and iron deficiency
• Other intolerance eg lactose

Question 8

Coeliac disease is linked to which other AI disease

Answer 8

• Type 1 diabetes
• Thyroid disease
• Screened for coeliac disease if have these

Also Down syndrome is related

Question 9

Where is gluten present? - which foods

Answer 9

Wheat
Barley
Rye

Question 10

Testing for coeliac disease

Answer 10

• Total IgA level
• Anti-TTG - tissue transglutaminase
• Anti-EMA - endomysial

Then endoscopy + jejunal biopsy = crypt hyperplasia and villous atrophy

Question 11

Complications of coeliac disease

Answer 11

• Nutritional deficiency
• Hyposplenism
• Anaemia
• Osteoporosis
• Cancer - small bowel lymphoma - enteropathy associated T cell lymphoma, NHL, small bowel adenocarcinoma

Question 12

Differentials for high frequency diarrhoea including at night, pain when needing to open bowels for 6 weeks

Answer 12

• IBD
• IBS
• Giardia, C.diff, campylobacter, salmonella / other infection

Question 13

IBD vs IBS

Answer 13

IBD:
* Unwell child - appear tired
* Maybe blood in stool

IBS:
* Seem well

Question 14

Investigations for ?infection/IBD/IBS

Answer 14

• Stool microscopy and culture - need to check if fecal calprotectin is true (infection inflammation can cause false +ve)
• Fecal calprotectin - for IBD
• Bloods - FBC (?anaemia, high Plt for inflam), CRP (inflam), ESR, ferritin (inflammation)
• Colonoscopy + biopsy
• Upper GI endoscopy for ?Crohns

Question 15

Management of IBD in children - broad

Answer 15

• Monitor growth
• Monitor pubertal development
• Monitor bone health - if using steroids
• Induction and maintenance regime

Question 16

Acute management for UC

Answer 16

• IV steroids

Question 17

Acute management for Chrohns

Answer 17

• Liquid diet enteral nutrition - for 8 weeks (esp if concerns re growth re steroids)
• Steroids (can sometimes add other immune drugs on top)

Question 18

Maintenance for UC

Answer 18

• Aminosalicylates (e.g., oral or rectal mesalazine) first-line
• Azathioprine
• Mercaptopurine

Question 19

Maintenance for Crohns

Answer 19

Azathioprine
Mercaptopurine

Question 20

Functional gastrointestinal disease (FGID) - umbrella term for

Answer 20

• No underlying cause found - to do with gut-brain relationship eg:
• Abdominal migraine
• IBS
• Functional abdominal pain
• Functional dyspepsia - nausea no vomitting

Question 21

What is important to check re GI symptoms and timing?

Answer 21

• Is there relationship with setting? eg does it happen at school?

Question 22

Differentials for neonate with jaundice <24hrs

Answer 22

Always pathological (and if occurs after few weeks too)
* rhesus haemolytic disease
* ABO haemolytic disease
* hereditary spherocytosis
* glucose-6-phosphodehydrogenase

Question 23

Jaundice cause day 2-14

Answer 23

• Usually normal - related to liver function, RBC fragility

Question 24

Cause of jaundice after 14 days of birth

Answer 24

• Biliary atresia
• Hypothyroidism
• Galactosaemia
• Urinary tract infection
• Breast milk jaundice
• Prematurity
• Congenital infections