Gastrointestinal System Flashcards
(92 cards)
1
Q
Vomiting vs Regurgitation
A
effortless process not accompanied by muscle contraction or
autonomic symptoms
2
Q
Process of vomiting
A
Retrograde contraction of proximal small bowel with regurg of duodenal contents
into the stomach
>
Contraction of abdominal muscles & diaphragm ✚ relaxation of lower oesophageal sphincter
>
Forceful expulsion of gastric content, accompanied autonomic symptoms
3
Q
Causes of vomiting
A
- Acute causes = Gastroenteritis, URTI, Food poisoning
- Acute dietary indiscretion
- Infection = UTI, Meningitis, Hepatitis, Encephalitis
- Diges+ve tract disorders Pep+c ulcers, Appendici+s, Intussuscep+on, Malrota+on, Childhood Menetrier’s disease, Achalasia
- Toxic & metabolic disorders, Drugs or poisons, Reye’s syndrome, Uraemia, DM, Hypercalcaemia
- Increased ICP
- Psychogenic/other = Migraine, cyclic vomiting, Bulemia
4
Q
History you should take for a child presenting with vomiting
A
- Content of vomitus
- Relationship with meals and time of the day
- Associated symptoms
- Medication
- Symptoms of other organ disease
5
Q
Describe the significance of knowing the content of the vomitus
A
- Undigested food: oesophageal strictures & achalasia
- Fresh blood/coffee ground: swallowed blood, gastri+s, oesophagi+s,
oesophageal or gastric varices - Bilious vomi+ng: intes+nal obstruc+on distal to 2nd part of the duodenum
6
Q
Significance of knowing relationship of vomiting to meals and time of the day
A
- Associated with specific foods: food allergy
- Accompanied by pain: pep+c ulcers
- AVer meals: inherited metabolic disease
- Early morning vomi+ng: “ ICP
7
Q
Associated symptoms significance
A
- Dysphagia or odynophagia: oesophagi+s, oesophageal strictures
- Diarrhoea: infec+on, food allergy, par+al intes+nal obstruc+on
8
Q
What medication can make kids vomit
A
theophylline & digitalis
9
Q
Associated signs with vomiting and what they indicate
A
- Jaundice ✚ tender hepatomegaly: hepatitis
- Headache or signs of incr ICP: meningitis, migraine, inherited metabolic disease, SOL, toxins, drugs
- Abdominal distension: intestinal obstruction
- Visible peristaltic waves & pyloric tumour: pyloric stenosis
- Abdominal tenderness (features of peritonitis): specific organ disease, e.g. hepatitis
- Abdominal mass: TB of the abdomen, tumour
- Hernia: examine for incarceration
10
Q
Danger signs of vomiting in paeds
A
- CNS symptoms: drowsiness,
headache, signs of “ ICP - Signs of intes+nal obstruc+on
- Bile-stained or faeculent
vomi+ng - Blood in the vomit
- Projec+le vomi+ng
- Dehydra+on
- Acid-base & electrolyte
abnormali+es - Weight loss
- Fever & other signs of systemic
infec+on
11
Q
Rx vomiting
A
- Rx underlying cause
- Rehydrate
- small vol feeds frequently
- metoclopramide oral
12
Q
GERD
A
= passage of gastric content into the oesophagus due to transient relaxation of the
lower oesophageal sphincter OR low LES tone (chalasia) associated with complications
13
Q
Symptoms of GERD
A
Esophageal symptoms
▪ Heart burn
▪ Acid regurgita/on
▪ Odynophagia/dysphagia
▪ Angina-like chest pain
▪ Water brash (hypersaliva/on)
Airway symptoms
▪ Throat clearing
▪ Globus
▪ Tracheal stenosis
▪ Pulmonary fibrosis
▪ Apnea in infants
14
Q
Investigations of GERD
A
- Barium swallow
- 24hr oesophageal pH monitoring
- Radio-isotopes
- Oesophagoscopy/biopsies
15
Q
Mx of GERD
A
- Severe malnutrition or resp complications: transpyloric feeds
- PPI for acid-related complications OR histamine receptor antagonists
- Surgery: reserved for GERD that does not respond to optimal medical Mx/
neurologically impaired children “ trans-abdominal fundoplication
16
Q
Complications of GERD
A
- Reflux Oesophagitis
- Respiratory Complications
- Dental Erosions
- FTT
17
Q
Reflux oesophagitis
A
- Symptoms: pain, refusal of feeds, posturing, haematemesis
- Fe-deficiency anaemia
- May cause peptic strictures of oesophagus “ intestinal metaplasia
(Barret’s oesophagus) “ precursor of oesophageal adenocarcinoma in
adults
18
Q
Respiratory problems in GERD
A
- Clinical: chronic cough, stridor, hoarseness, aspiration pneumonia,
recurrent wheezing & bronchiectasis - Aggravates asthma
- Associated conditions: OM & sinusitis
19
Q
Warning signs of GERD
A
- persistent vomiting
- bilious vomiting
- constipation
- diarrhoea
- signs of neurologic disease = macrocephaly, seizures, hypertonia
- abdominal tenderness or distension
- hematemesis
- hepatosplenomegaly
- FTT
20
Q
Recurrent abdominal pain definition
A
Recurrent abdominal pain where no cause can be found occurring at least monthly for 3 consecutive
months with severity that interferes with routine function of the child
Typically periumbilical pain associated with
belching, bloating with negative findings on clinical evaluation and no response to acid-blocking medication
21
Q
Irritable Bowel Syndrome presentation
A
pain below the umbilicus accompanied by abdominal cramps, bloating and distension and with and altered bowel
pattern
22
Q
Constipation definition
A
delay or difficulty in defecation (< 3 stools per week), present for ≥ 2 weeks &
sufficient to cause significant distress to patient
23
Q
Classification of constipation
A
- By course: acute or chronic (>8wks)
- By etiology:
- 1° (function): no iden0fiable medical disorder (in children > 1 y/o)
- 2°: due to medical disorder or medication (< 1 y/o)
24
Q
Faecal soiling
A
Involuntary leakage of small amounts of soft or watery stool 2° to faecal loading & rectal distension
25
What classifies as functional constipation in infant or toddler
One month of >2 of the following:
* ≤ 2 defecations per week
* Hx of excessive stool retension
* Hx of painful or hard bowel
movements
* Hx of large diameter stool
* Hx of large diameter stool which
may obstruct toilet
* Presence of large fecal mass in
rectum
* ≥ 1 episodes/week of incon0nence
aRer acquisi0on of toile0ng skills
26
What classifies as functional constipation in child or adolescent
>2 of the following for at least 1 week. (For >1month for dx of IBS)
* ≤ 2 defecations in toilet per week
* Hx of painful or hard bowel
movements
* Presence of large fecal mass in
rectum
* Hx of large diameter stool which
may obstruct toilet
* ≥ 1 of fecal incontience per week
27
Causes of constipation
* Incorrect diet (insufficient fibre and fluid)
* Lack of exercise
* Psychogenic and behavioural problems
* Chronic use of enemas
* Certain drugs (opiates and anticholinergics)
* Uncommon: Metabolic abnormalities, hypothyroidism, neurogenic or lower bowel abnormalities
28
Nonretentive fecal incontinence definition
involuntary or intentional passing of stool outside the toilet, without evidence of constipation or underlying medical conditions
29
Criteria for dx of nonretentive fecal incontinence
≥ 1 month Hx of following symptoms in children > 4 y/o:
1. Defecation into places inappropriate to sociocultural context
2. No evidence of faecal retention
3. After appropriate medical evaluation, faecal incon0nence cannot be explained
30
Pathophysiology of altered bowel motility
Alteration in bowel innervation lead to ineffective peristalsis:
▪ Drugs: altered autonomic outflow & bowel muscle contraction
▪ Endocrine pathology: downregulated
bowel motility
▪ Neurological pathology: disease or
trauma of bowel innervation
= sensation of incomplete & irregular bowel emptying
31
Causes of motility disturbance
*Neurogenic: Hirschprung disease
*Myogenic: smooth muscle
*Prune belly & Down syndrome
*Gastroschisis
32
Anatomical causes for constipation
Imperforate anus
Anal stenosis
Ant displacement of the anus
Pelvic mass: sacral teratoma
Abnormalities of spinal cord or peripheral nerves
▪ Tethered cord
▪ Neurofibromatosis
▪ Visceral myopathies or neuropathies
33
Metabolic Causes of Constipation
* Hypothyroidism
* Hypercalcaemia
* Hypokalaemia
* DM
* Renal tubular acidosis
* MEN type IIb
34
Connective tissue disorders of constipation
* Scleroderma
* SLE
35
Abdominal Wall defects causing constipation
* Prune Belly
* Diaphragmatic Paralysis
36
Malabsorption Syndromes causing constipation
* CF
* Coeliac Disease
37
Drugs causing constipation
CCB
Opiates
Phenobarbitone
Antacids, An0spasmodics
An0cholinergics, An0depressants
38
Diagnosis of constipation
* History of infrequent passage of hard stools.
* Non-tender deformable faecal masses palpable.
* Prolonged severe constipation may present with overflow “diarrhoea” or faecal soiling
39
Mx of Constipation
First treat underlying cause
1. Faecal clearance
2. Prevent re-accumulation of hardened retained stool
3. Retraining of the gut to achieve regular toilet habits
40
What does faecal clearance "disimpaction" entail?
* Phosphate-containing enema (Golytely / Klean-prep) 20ml/kg/hour until stools are clear. (In small children be
careful of severe electrolyte shifts)
* Paediatric fleet enema PR stat
* Oral lactulose, PEG, Parafine, Sorbitol
41
Investigations for constipation
1. Urine dipstix
2. AXR
3. Exclude rare causes only if clinical signs (hypothyroidism, Hirschsprungs, ano-rectal malformation)
42
Describe the maintenance of care for constipation
* Explain to parents bowel re-education may take months
* Toilet after meals regardless
* Star charts with rewards for success
* Additional fluid intake
* Dietician referral
* High fibre diet
* Lactulose (Alternative Sorbitol, Movecol)
* Additional fibre (Fybogel Orange)
* Children 6 years or older: In severe cases add Senokot or Bisacodyl
43
Red Flags in constipation
1. Constipation when < 1mo old
Family Hx of disorders that may cause constipation
Delayed passage of meconium > 48 hours = Hirsch, CF, Intest malformaiton
2. Explosive stool release aRer PR = Hirschprung's
3. FTT = Hirsch, CF, Malabsorption, Coeliac
4. Change in infant formula = cow's milk protein enteropathy
5. Severe distension, Bilious vomiting = obstruction = intestinal atresia, malrotation, pyloric stenosis
6. Blood in stool = obstruction, anal fissure, inflammatory bowel disease
7. Lumbar spine abnormalities = spina bifida occulta
8. Perianal fistula, bruising, fissures = IBS, Spinal cord lesions
9. Lower limb abnormalities decr tone/strength
10.Abnormal abd wall musculature = prune belly
11. Thyromegaly
12. Fever
44
Osmotic laxatives
These are poorly absorbed and they are hyperosmolar which increases the water content in the food = softer stool = easier to pass
PEG
Lactulose
Sorbitol
S/E = diarrhea, dehydration, severe flatulence
45
Stimulant laxatives
eg. Senna
Acts on mucosa of intestine increases the water and electrolyte secretion. Stimulates peristaltic action
46
Lubricants prescribed
Mineral oil, Liquid paraffin
Softens the stool and decreases water absorption
47
Difference between dehydrated and shocked?
Dehydration
* Increased skin tugor
* Sunken frontanelle
* Sunken eyes
* Dry mucous membranes
* Capillary filling assess
Shocked
* Hypotension
* Tachycardia
* Dehydration
* Late: drowsy, decreased responsiveness
48
Investigations for Gastro
- Ward Hb If < 10 g/dL = do FBC
- Dipstick If < 6 months OR
nitrates/leucocytes on dips.ck OR
GE > 5 days OR
malnourished/FTT # do MC&S
- U&E If dehydrated
- RVD If not done before or breast feeding >> do rapid
- ABG Post fluid resus
if in shock
- CMP
- ALT
- BC
49
Mx of gastro
* ZnSO4:
- < 6 months: 10 mg/day, orally
- > 6 months: 20 mg/day, orally
* GE > 5 days - bowel cocktail:
- Gentamycin 8 mg/kg, 4 hourly, orally, for 3 days
- Metronidazole 7.5 mg/kg, 8 hourly, orally
50
What is the purpose of Zinc in mx of AGE
decreases the duration & severity of diarrhoeal episodes and likelihood of subsequent
infections for 2–3 months
51
Mx when gastro is complicated with other problems?
1. Dysentery = add Ceftriaxone/ Cipro
2. Entamoeba Histolytica = add Metronidazole
3. Typhoid = Cephtriaxone
4. Chronic diarrhoea = Gentamycin / Metronidazole
52
Approach to Abdominal Mass
* Epigastrium
- Distended stomach (pyloric stenosis)
* Flanks
- Nephroblastoma
- Neuroblastoma
- Mesoblastic nephroma (benign; < 6 months)
- Hydronephrosis
- Polycystic kidney
* Right upper quadrant
- Hepatoblastoma
- Hepatomegaly
* Left upper quadrant
- Splenomegaly
* Right iliac fossa
- Appendiceal abscess
* Faecal impaction
* Lymphoma
* Bladder
53
Causes of Unconjugated Hyperbilirubinaemia
1. Increased Hb breakdown:
* Hemolysis
* Dyserythropoiesis
* Resolving haematoma/internal
haemorrhage
2. Impaired uptake of biliruin:
* Drugs
* Portsystemic shunt
3. Defective conjugation:
* Inherited: Gilbert’s
disease
* Neonatal jaundice
* Liver disease
* Hyperthyroidism
54
Causes of conjugated hyperbilirubinaemia
1. decreased excretion/reuptake of bilirubin:
* Inherited
2. Intrahepatic cholestasis (Cholestasis = reduction or stoppage of bile flow)
* Idiopathic neonatal hepatitis
* Hep A/B
* Toxins: paracetamol
* Infiltration
* Storage/metabolic disease:
* Wilson’s disease
* α1-an=trypsin deficiency
2. Extrahepatic cholestasis:
* Biliary atresia, choledochal
cysts
* Gallstones, neoplasia,
massive LNs
* Inspissated bile syndrome
* CF
* Neonatal sclerosing
cholangitis
55
Main difference between unconj and conj BR
- Unconj = lipid soluble toxic to the brain; carried through
circula=on bound to albumin
- Conj = water soluble, excreted via bile and kidneys
56
Obstructive jaundice
urobilinogen
dark urine
pale stool (no stercobilin)
57
Acutely ill NB red flag causes of Jaundice
* Fulminating liver
failure
* Septicaemia
* Shock
* Acute cholangitis
* Metabolic
* Toxic
58
History to take when a child presents with jaundice
1. Associated symptoms:
- Fever
- N&V
- Anorexia
- Fatigue
- Rash
- Sore throat
- Abdominal pain
- Pruritis
2. Past medical Hx:
- Previous jaundice/liver disease
- Exposure to blood products
- Worms
- TPN
3. Drug or toxin exposure: paracetamol, dapsone, rifampicin, isoniazid,
pyrazinamide, phenytoin, sulphonamide, HCTZ, tradi=onal meds
4. Recent travel: to malaria or bilharzia area
59
Definition of Acute Liver Failure
= multisystem disorder with severe impairment in liver function: incr INR, " albumin ±encephalopathy
massive necrosis of
liver cells leading to the development of hepatic encephalopathy.
60
Diagnostic Approach to Acute liver Failure
1. Viral = Hep ABC, EBV, CMV, Herpes, Adeno, Entero, Influenza, Parvo, Lepto, Congenital
2. Drugs/Toxins = Paracetamol, AntiTB, cART, Antiepileptic, mushroom poisoning
3. Autoimmune
4. Inherited Metabolic disease
5. Other
61
Examples of Inherited metabolic disease
* Neonatal
haemochromotosis
* Mitochondrial cytopathy
* Galactossaemia
* Tyrosinaemia
* Urea cycle defects
* Nieman Pick type C
* FaZy acid oxida&on
* Hereditary fructose
intolerance
Older children > Wilson's disease
62
"Other" causes of Acute liver failure
* Vascular: haemo-occlusive disease
* Haemophagocytic lymphohistiocytosis
* Lymphoma
* Liver tumours
* Ischaemia
* Acute congestion
63
Causes of acute liver failure
*Infection: Hep A, B, C, E
EBV, CMV, HIV, herpes
ECHO
*Drugs & toxins: Paracetamol & salicylic acid levels
*Autoimmune: Incr globulin = do: ANA, RF, ASMA, ANF, an&-KLM
Abdominal U/S. Treat with steroids
*Metabolic Ferritin, α1-anti-trypsin, urine reducing substances
*Vascular Abdominal U/S: examine large vessels (portal vein, IVC),
tumours, liver size, spleen
64
Prevention of
gastric bleed
1. H2-antagonist
2. PPI
3. Sucralfate (mucosal protectant)
65
Most common cause of death in acute liver failure?
Cerebral Oedema
Restrict fluid intake
Signs of herniation: Mannitol IV stat
66
Complications of Acute Liver failure
* Coagulopathy
* Hypoglycaemia
* Cerebral oedema
* Renal failure
* Encephalopathy
* Cardiorespiratory failure
* Metabolic acidosis
* Sepsis
67
Mx of Acute Liver failure
1. Monitor: BP, Urine output, HR, Neurological state, Resp, GI bleeding, Hct, Sglucose, acid-base status, LFT, Renal func, INR, Electrolytes
2. Treat shock
3. NPO initially reduce protein load
4. Treat hypoglycemia
5. AB therapy where sepsis suspected Ampicillin
6. Lactulose to reduce intestinal protein absorption
7. treat GI bleed with omeprazole
8. treat Cerebral oedema with mannitol
9. treat coagulopathy with Vit K
10. packed red cells for anaemia
11. Diazepam for seizures caused by acute liver failure
12. Genta to decontaminate the gut
13. Mycostatin for fungal prophylaxis
14. N-acetylcysteine infusion for paracetamol poisoning
68
Role of Vit K in Mx for acute liver failure
Treat coagulopathy
treat the active bleeding
give FFP
69
Role of N-acetylcycsteine
Parvolex regime according to weight
Take care with asthmatics
- Give hydrocortisone and anti-histamine
70
Definition of Chronic Liver disease
= present for > 3 months
Can progress to cirrhosis
71
Causes of chronic liver disease
* Infectious: HBV, HCV, CMV
* Drug-induced: methotrexate
* Metabolic: Wilson’s disease, α1-anti-trypsin deficiency, CF
* Autoimmune: autoimmune hepatitis, 1° sclerosing cholangitis, steatohepatitis
* Biliary arteria (major cause in children)
72
Signs of chronic liver failure
* Palmar erythema
* Clubbing (biliary cirrhosis)
* Spider angioma
* Gynaecomastia/testicular atrophy (oestrogen dependent - only in older boys)
73
Signs of cholestasis:
* Jaundice (non-specific)
* Pruritis ! scratch marks
* Xanthomata (chronic cholestasis)
* Dark urine & pale stools
74
Cirrhosis
* Normal architecture of the liver is destroyed
* Chronic injury to the liver = fibrosis & scarring = replacement of normal
liver architecture by regenerative nodules
75
Main categories for causes of cirrhosis
1. 2° to bile duct obstruction
2. Post-necrostic cirrhosis
76
2° to bile duct obstruction causes of chronic liver failure
o Biliary atresia
o Choledochal cyst
o CF
o Bile duct stenosis/obstruc5on:
gallstone, neoplasia, LNs
o Ascending cholangitis
77
Post-necrostic cirrhosis causes of chronic liver failure
Post hepa5c:
o Neonatal hepa55s
o Viral hepa55s
o Chronic hepa55s
o Drugs
Venous conges5on:
o Constric5ve pericardi5s
o CCF
o Budd-Chiari
o Veno-occulsive disease
Gene5c causes:
o Wilson’s disease
o Glycogen storage disease
o Galactosaemia
o α1-an5trypsin deficiency
78
Clinical features of cirrhosis
Chronic liver disease
Portal HTN
Liver failure
General: Growth failure, Delay in 2° sexual characteris5cs
Hands: Clubbing, Leukonychia
Trunk: Spider nevi, Caput medusae, Gynaecomas5a
Liver: firm & irregular
79
Complications of chronic liver disease
1. Portal HPT
2. Synthetic dysfunction
3. Hepatic encephalopathy
4. Hepatopulmonary syndrome
5. Porto-pulmonary HTN
6. Hepatorenal syndrome
7. Hepatic Hypertrophic osteoarthropathy
8. Hepatocellular Carcinoma
9. Nutritional Compromise
80
Synthetic
dysfunction
1. Coagulopathy
2. Hypoalbulinaemia
81
Hepa2c
encephalopathy
* Reversible neuropsychiatric abnormali5es
* Grade I (normal cogni5ve func5on) ! IV (overt hepa5c
encephalopathy)
* Presenta5on: personality changes, intellectual
deteriora5on, altered LOC, asterixis
82
Hepatopulmonary
syndrome
* Oxygenation (arterial hypoxaemia) defect induced by
pulmonary vascular dilatation in the setting of liver cirrhosis/portal HTN
* Due to shunting of vasodilatory mediators from the
mesentary away from the liver; incr intrapulmonary
shunting
* Clinical: cyanosis, incr dyspnoea, clubbing (absence of 1°
cardiac or pulmonary disease)
83
Porto-pulmonary
HTN
* Pulmonary arterial pressure > 25 mmHg, > 30 mmHg
with exercise & incr pulmonary vascular resistance
* Clinical presentation: exertional dyspnea & RHF
84
Hepatorenal syndrome
* Development of renal failure in patients with chronic
liver disease, with portal HTN & acites
* Type 1: rapid & progressive renal impairment;
precipitated by SBP
* Type 2: moderate & stable reduction in GFR in patients
with rela5vely preserved hepatic function
85
Definition of Portal Hypertension
= portal pressure > 10 mmHg or hepa3c pressure gradient > 4 mmHg
86
Causes of Portal Hypertension
Pre-hepatic
* Portal or splenic vein obstruc2on
* Congenital stenosis of portal vein
* Extrinsic compression of portal vein
Intra-hepatic (pre-
& post-sinusoidal)
* Cirrhosis
* Schistosomiasis
* Congenital hepa2c fibrosis
* Nodular regenera2ve hyperplasia
* Veno-occlusive disease
* Granulomatous disease: sarcoid, TB
Post-hepatic
* Budd-Chiari syndrome
* IVC thrombosis
* Congenital malforma2on of the IVC
* Constric2ve pericardi2s or heart failure
87
Clinical Sx of Portal Hypertension
* Significant GI bleeding (oesophageal or gastric varices OR portal HTN
gastropathy)
* Unexplained splenomegaly: petechiae or ecchymosis
* Other: ascites, periumbilical vascular collaterals, rectal varices
* Intrahepa3c & posthepa3c: hepatomegaly
* Cirrhosis: hepa3c decompensa3on & encephalopathy
88
Variceal bleed
Pressure gradient between portal & hepa3c veins increases > 10 mmHg
Prevention: oral non-selective β-blocker (propranalol)
89
Approach to an acute bleed
- resus
- coagulopathy: Vit K & FFP
- control bleed: somatostatin
- ligation
90
Acute Hepatitis classification
1. Infectious
Hepatotropic viruses:
Hep A, B, C, D, E, F, G
Other viruses:
Measles
Rubella
Parvo B19
Enteroviruses: coxsackie,
echo
HVH 1, 2, 6
CMV
EBV
Non-viral:
Bacteria: Salmonella, MTB
Protozoa
Parasite
2. Non-infectious
Toxins & drugs
Metabolic
Autoimmune
91
Chronic Hepatitis classification
1. Infections:
* Hep B, C
* HIV
- Coninfec&on: HBV
- Biliary complica&ons:
post cryptosporidium
2. Autoimmune
3. Toxins & drugs
3. Metabolic/inherited disorders:
(< 5 y/o)
* Galactossaemia
* Tyrosinaemia
* Mitochondral cytopathy
* Nieman Pick
* Familial cholesta&c
syndromes
(> 5 y/o)
* α1-an&trypsin deficiency
* Wilson’s disease
4. Biliary tract abnormali&es
5. Idiopathic
92
Hepatitis A
