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Gastrointestinal Flashcards

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1
Q

GORD Referral paeds

A

SAME Day if haematemesis, melaena, dysphagia
Assessment if red flag sx
Refer if Cx

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2
Q

Red flags for paeds GORD

A 
Faltering growth
Unexplained distress
Unresponsive
Unexplained IDA
No improvement after 1yr
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3
Q

Cx of paeds GORD

A 
Reccurent aspiratoion pneumonia
unexplained apnoea
unexplained epileptic like seizure
Unexplained upper airway inflam.
dental erosion w/neurodisability
recurrently acute otitis media
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4
Q

2 Mx of GORD

A

Reasure: v common, <8wks old, self resolves

R/v only if: projectile, bilestained vomit/haematemesis, >1yr

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5
Q

Non-pharm Mx of GORD

A

NOT positional while asleep
Bf: assess bf, if issue persists try alginate therapy for 1-2w (stop at intervals to assess)
FF: R/v Feeding Hx, aim for 150-180ml/kg/day, offer thickened formula, alginate therapy

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6
Q

Pharm Mx of paed GORD

A 
4 wk trial of PPI/histamine antagonist if 1+:
- unexplained feeding diffuclty
- distressed behaviour
- faltering growth
(also if complaining of heartburn)
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7
Q

PACES of GORD in paeds

A

Dx: immaturity of foodpipe leads to food coming back up
Is common usually self resolves
BF: assess, alginate
FF: r/v feed Hx, smaller volumes, thickener, alginate
safety net: if green or bloody seek help

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8
Q

Pyloric stenosis

A

Ix: USS, U+E
IV fluid resus. essential to correct electrolyte imbalance before surg. (1.5x maintenance rate w/5% dextrose+0.45%saline)
Ramstedt pyloromyotomy
(divide down to but not inc. mucosa)

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9
Q

Infant Colic

A

Reassure is common and tends to self resolve
Information: NHS choices, health visitor
Try holding baby w/gentle motion, white noise
Encourage parents to look after themselves too w/support and sleep
NB. infacol and coleif have insuf. evidence

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10
Q

Appendicitis in paeds

A 
Ix: FBC, urine pregnancy test, CT abdo 
Surgical emergency:
admit, NBM
IV fluids
appendicectomy (?cefoxitin IV)
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11
Q

Intussusception Ix

A

USS
AXR if suspecting obstruction
Contrast enema

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12
Q

Intusseusception Mx

A

ABCDE
?IV fluids/NG feeding
Unless signs of peritonitis attempt rectal air insufflation (w/fluoro guidance by a radiologist)
- 25% will need surgery

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13
Q

Contraindications to contrast enema reduction in intussusception

A

Peritonitis
Perforation
hypovolaemic shock
Broad spec ABx (clind+gent/tazocin/cefotixin+vanc)
2nd line: surgical reduction w/broad spec ABx

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14
Q

Recurrent intussusception

A

Consider investigation for pathological lead point eg Meckels diverticulum

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15
Q

PACES counselling of Intussusception

A

Dx: part of bowel has become stuck to another telescopically
Young children
May need NG/IV
Explain procedures (air insuff. -> operation 25%)
5% risk of recurrence (usually within days of treatment)

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16
Q

Meckel’s Diverticulum

A

Ix: T99m pertechnetate
Asymptomatic: Incidental finding, no Mx, if detected surgically excise as prophylaxis
Symptomatic:
- bleeding: excise w/trx if Hb unstable
- obstruction: excision and adhesiolysis
- Perforation/peritonitis: excision or small bowel segmental resection + Abx

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17
Q

Malrotation

A

Ix: upper GI contrast, CT abdo w/contrast, AXR
If signs of vascular compromise: EMERGENCY laparotomy
Ladd procedures derotates the bowel by dividing Ladd band
Duodenojejunal flexure placed on right and caecum and appendix on left (appendix usually removed)
ABx: cefazolin

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18
Q

Recurrent Abdominal pain

A

Inspect for anal fissure, check growth of child
Urine MC&S
Abdo USS (gallstones, ureteric obstruction)
Coeliac antibodies and TFTs
IBS and functional dyspepsia are Dx of exclusion

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19
Q

Abdominal migraine

A

offer anti-migraine meds

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20
Q

IBS Advise to parents

A

Reassure

Encourage patient to ID sources of stress/anxiety or foods that may aggravate symptoms

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21
Q

Peptic ulcer Dx in children

A 
if suspected: lansoprozole 30mg
Ix for H pylori
If positive;Amox+metroORclari
If this fails upper GI endoscopy
- if normal: functional dyspepsia
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22
Q
  • 7d triple therapy in peptic ulcer Dx:
A

PPI BD, 1g amoc BD + clari 500mg BD or metro 400 mg BD

If penicillin allergy omit amox and use other 3

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23
Q

Eosinophilic oesophagitis

A

oral corticosteroids (fluticasone or budesonide)`

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24
Q

Gastroenteritis in children

A 
Assess for: dehydration and shock
Consider admission
Rehydration
?stool analysis
prevent spread
FU
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25
Maintenance and Rehydration volumes in children
``` Maintenance: 0-10kg = 100ml/kg 10-20 = 1000ml + 50ml/kg >10 20+ kg = 1500ml +20m/kg >20 Rehydration <5: 50ml/kg over 4hrs as well as maintenance w/oral hydration solution >5: 200mL ORS after each loose stool ```
26
Notifiable gastroenteritis
``` campylobacter Listeria E coli 0157 Shigella Salmonella ```
27
Dehydration in children
likely viral cause Ix: U+E, FBC, stool MC+S only if bloody diarrhoea Mx: ORS, IV fluids only for shock, deterioration or persistent vomiting
28
Fluid resuscitation in children
Glucose free crystalloids w/Na in the range 131-154 Bolus of 20ml/kg over <10m - different in DKA bc of risk of cerebral oedema
29
IV fluids monitoring
Glucose and electolytes at least evert 24hr
30
Neonatal fluid requirements and resus
``` Maintenance (day): 1: 50-60ml/kg 2: 70-89ml/kg 3: 80-100ml/kg 4: 100-120ml/kg 5-28: 120-150ml/kg for neonates use isotonic crystalloids w/5-10% dextrose ```
31
Hypernatraemic dehyration
ORS first line If IV introduce slowly to avoid cerebral odema Replace deficit over 48hrs
32
Antidiarrhoeal and antiemetics in children
``` NOT used ineffective SE focus away from rehydration increased time sheding bacteria in stool ```
33
Gastro indications for Antibiotics in children
``` NOT routinely gastroenteritis ONLY for: suspected/confirmed sepsis extra-intestinal spread salmonella gastroenteritis if <6m Malnourished or IC children Specific infections: C dif, cholera, shigell ```
34
Nutrition after diarrhoea
needs increasing | ?Zn deficiency
35
Post-gastroenteritis syndrome
introduction of normal diet causes watery diarrhoea | start ORS
36
Coeliac Dx Ix
Ix: FBC+ smear (macrocytic an.), Serology (anti-tTG, anti-EMA (if IgA def. IgG DGP)) OGD and duodenal biopsy (v. young may have confirmatory EMA + HLADQ2/8 testing instead)
37
Coeliac Dx Mx
``` Remove all wheat, rye, barley Referral to dietician Annual r/v: - height, wt, BMI - Sx - Adherence to diet -?bloods (serology, FBC, TF, LFT, vit D/B12, folate, Ca) ```
38
Non-adherence to coeliac diet
micronutrient def. (osteopenia) small increased risk of bowel ca esp small bowel lymphoma hyposplenism
39
PACES counselling of coeliac dx
``` Dx; unable to digest gluten Common 1 in 100 Mx: gluten free diet Dietician Importance of diet FU necessary every 6-12m Regular height and weight measurements Support: coeliac UK ```
40
Crohns Dx Ix
``` FBC (inc. Fe, B12, folate) CRP + ESR ?Stool testing Upper GI and small bowel contrast scan Colonoscopy and biopsy ask about impact on life ```
41
Education for Crohns pts
``` Stop smoking (Reduce relapse) risk of osteoporosis unintended wt loss could be sign of flare do NOT have live vaccines if on IS Mx ```
42
Medical Mx of Crohns Dx
Steroids (pred) to induce and maintain remission IS drugs (azothioprine, MTX) Biologics (infliximab) Aminosalycates (mesalazine)
43
PACES Counselling of Crohns Dx
``` Dx: unkown cause, inflammation, malabs, diarr. Life long w/relapses Mx by gastroenterologist medically Cx: malabs and cancer no special diet but may find triggers Suport: Crohns and Colitis UK ```
44
Ulcerative colitis Assessed by:
Paediatric ulcerative colitis activity index (PUCAI) Sev: >65pts Mild-mod:>10-64
45
Mild-moderate proctitis in UC in children
Oral and/or topical aminosalicylates | Second line: topical corticosteroid or pred PO
46
Mild left sided and extensive UC in children
PO aminosalicylate consider adding topical AS, PO beclometasone Alternative: PO pred
47
If no improvement after 4 wks of aminosalicylate therapy in UC in children
``` Consider adding oral pred if still no: PO tacrolimus biologicals: infliximab, adilimumab - surgery and option ```
48
Maintaining remission in UC in children
AS mainstay | consider PO azothioprine or mercaptopurine if requiring steroids freq.
49
Severe fulminating UC in children
``` EMERGENCY - do they need surgery? Increased risk of needing surg: >8 stool/day Pyrexia tachycardia AXR w/colonic dilatation Low: albumin, HB, High: plt. CRP Offer IV corticosteroids to induce remission (second line ciclosporin) ```
50
Surgical Mx of fulminating UC in children
Colectomy w/ileostomy or ileojejunal pouch
51
PACES for UC
Unknown cause, inflammation of bowel -> Sx 1:420 No cure, Dx will come and go Medications available to reduce flares and treat when they happen Cx: growth issues, bowel ca FU: will be seen by gastroenterologist
52
Constipation in children
Exclude red flag symptoms Laxatives (several mo. possibly) Examine for impaction (commence disimpaction is present) Otherwise: maintenance laxative rx Behaviour intervention (gastrcolic reflex, star chart) Diet and lifestyle (hydration) FU to assess response
53
Disimpaction therapy
step 1: movicol paed plan (polyethylene glycol + electrolyte) escalating dose 2w step 2: Add a stimulant (senna/sodium picosulphate) - If movicol not tolerated a stimulant can be used w/lactulose or docusate (softners)
54
Maintenance therapy for constipation in children
Movicol +/- stim. laxative | Reduce dose over monthsi in respoonse to improvement
55
Types of laxative
Bulk forming: fybogel, methylcellulose Osmotic: lactulose, movicol Stim.; Bisacodyl, senna, sodim picosulphate stool-softener: arachis oil, docusate
56
All else fails constipation in children
enema | manual evacuation under anaesthetic
57
Constipation in under 1yr old
Increase fluids lactulose neonates may not poo for days if they are absorbing milk like nobody's business
58
PACES of Constipation in children
``` Simple constipation is very common Mx: break cycle or hard stool to pass Takes time for movicol to work - disimpaction 2w escalating dose - maintenance long term until habits reestablished Encourage gastrocolic reflex Behavioural motivation interventions emphasises is safe long term, most common cause of failure is inadqeuate use Aim: 1+ large soft stool ```
59
Hirschprung Dx Ix
AXR (if obstructed), contrast enema (narrow aganglionic segment) Definitive: full thickness rectal biopsy
60
Hirschprung Dx Mx
Initally bowel irrigation Surgical: colostomy followed by anastamosis of innervated bowel and anus aka anaorectal pull-through Total colonic agangliosis would require initial ileostomy w/later corrective surgery
61
Anal fissure in children
Ensures stools soft (fibre, fluids, ?laxative) Pain: simple analgesia, warm bath Importance of anal hygiene Advise against stool holding IF not improved in 2w or significant pain present again consider topical anaesthetic or GTN
62
Threadworm in children
Exclusion NOT required Single dose of mebendazole (repeat in 2wks if persistent) Children <6m hygiene alone, <6w seek ID specialist Trace contacts Rigorous hygiene 2wks if medendazole, 6wks if hygiene alone
63
Rigorous hygiene for threadworm
Hand washing cut nails regularly, avoid scratching anus shower each morning and wash perineum Change bed linen and nightwear nightly for several days (do NOT shake and wash on hot cycle) dust and vacuum

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