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GI Flashcards

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1
Q

What is gastro-enteritis?

A

Diarrhoea that occurs when intestinal fluid output overwhelms the absorptive capacity of the GI tract

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2
Q

Why does diarrhoea happen?

A

(1) Damage to the villous brush border of the intestine, causing malabsorption of intestinal contents and leading to an osmotic diarrhoea (CF, lactose intolerance, IBD, coeliac)
(2) The release of toxins that bind to specific enterocyte receptors and cause the release of chloride ions into the intestinal lumen, leading to secretory diarrhoea (infection, post-antibiotics)

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3
Q

What is oral rehydration therapy

A

1:1 ratio of sodium and glucose

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4
Q

Difference between watery stools, blood/mucus and steatorrhoea

A

Frequent, watery stools are more consistent with viral gastroenteritis, while stools with blood or mucous are indicative of a bacterial, steatorrhoea in coeliac, CF

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5
Q

Does the time scale of diarrhoea give a clue to its pathology?

A

Yes

A long duration of diarrhoea (>14 days) is more consistent with a parasitic or noninfectious cause of diarrhoea

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6
Q

Causes of vomiting in children?

A

GI: GORD, gastro-enteritis, constipation, overfeeding
Allergy/intolerance
Toxic ingestion
Obstructive: pyloric stenosis, intussessption, intestinal malrotation
Vestibular: Migraine/motion sick/labyrinthitis
CNS: Concussion, meningitis, raised ICP
Metabolic: DKA, Addison’s, CAH
Behavioural: Bulemia nervosa

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7
Q

Differential to gastro-enteritis

A

Hepatitis, IBD, appendicitis, DKA, lactose intolerance, pancreatitis, pyelonephritis, UTI, intussusception, pyloric stenosis, septic shock, toxic ingestion, overflow constipation

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8
Q

Common bacterial causes of gastro-enteritis

A

Enterotoxic E. Coli, Campylobacter, Salmonella, C. diff, Shigella

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9
Q

Common viral causes of gastro-enteritis

A

Rotavirus, noroviruses, enteric adenovirus

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10
Q

Common parasitic causes of gastro-enteritis

A

Giardia, cryptosporidium

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11
Q

When would you send a stool sample in suspected gastro-enteritis

A

If:
C. diff is suspected
Blood in stool
Parasites likely

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12
Q

Difference between reflux and GORD disease?

A

Reflux is relaxation of the lower oesophageal sphincter

GORD disease is reflux oesophagitis • Barrett’s oesophagus • Respiratory complications • Failure to thrive

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13
Q

Symptoms of GORD

A
  • Vomiting
  • Irritability
  • Coughing after feeds.
  • Sandhifer syndrome
  • Failure to thrive
  • Refusal to feed
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14
Q

What is Sandhifer syndrome?

A
  • Reflux causes baby to extend and spasm until acid returns to stomach (spasmodic torsional dystonia)
  • Accurate Hx needed to distinguish this from infantile spasms
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15
Q

Treatment of infant GORD?

A

Tilting bed and not lying infant down after feeds
Thickening the milk
Adding gaviscon into the milk which thickens and decreases acidity
Decrease volume and increase freq of feeds Omeprazole

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16
Q

Red flags of GORD

A 
Forceful and frequent 
<2months old
Bile stained
Haematemesis
Onset >6 months or persists >1yr
Blood in stool
Abdominal distension/mass/tenderness, Systemic unwell
Faltering growth or weight loss
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17
Q

How do you test for a food allergy?

A

Response to elimination for 3-4 weeks AND reintroduction

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18
Q

Symptoms of a food allergy in infants

A 
GORD
Loose /frequent stools
Blood/mucous in stools
Abdominal pain
Infantile colic
Food refusal/aversion
Constipation (straining on a soft stool)
Perianal redness
Pallor and tiredness
Faltering growth
Eczema
-> if CHRONIC
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19
Q

What is lactose intolerance

A

Inability to digest lactose into its constituents, glucose and galactose, secondary to low levels of lactase enzyme in the brush border of the duodenum

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20
Q

Symptoms of lactose intolerance

A

Loose stools, abdominal bloating and pain, flatulence, nausea, and borborygmi (stomach rumbles)

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21
Q

Cause of symptoms in lactose intolerance

A

The combined increase in faecal water, intestinal transit, and generated hydrogen gas accounts for the wide range of gastrointestinal symptoms

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22
Q

What is secondary lactose intolerance?

A

Damage of the brush border

Usually after acute illness (eg. giardiasis, gastroenteritis, Crohn’s, HIV enteropathy, Chemo)

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23
Q

What are risk factors for constipation?

A

LAC (looked after children), physical disability, toddlers, Down’s and autism

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24
Q

Red flags in constipation

A
  • Constipation from birth (hischsprung? congenital defect in GI system)
  • Previously unknown leg weakness/delayed gross motor (spinal cord?)
  • Abdominal distension with vomiting (bowel obstruction?)
  • Faltering growth (CF, coeliac)
  • Non responsive to treatment within 3 months
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25
What is hirschsprung disease?
* Functional obstruction of the gut due to lack of innervation and ganglia in the distal colon * -> increased smooth muscle tone and intrinsic enteric relaxing impulses are lost * Developmental disorder, usually diagnosed in newborn period if there is a failure of passage of meconium in the first 24-48hrs after birth & distended abdomen.
26
How do you diagnose hischsprung disease?
Diagnosed with contrast enema and full thickness rectal biopsy
27
How do you treat hischsprung disease?
Removal of aganglionic bowel using intestinal pull through (Soave)
28
Signs of a congenital pyloric stenosis?
* Presents in 1st 3-4 weeks of life with projectile, non bilious vomiting after feeds * Baby is malnourished and always hungry * Pyloric mass felt in RUQ in test feed
29
Treatment of pyloric stenosis
Correct alkalosis Stabilise ions Hydrate Pyloromyotomy
30
What is intussusception? What happens if untreated?
Small bowel telescopes (swallowing itself by invagination) | Untreated-> necrotic bowel
31
Signs and symptoms of intussusception?
* Presents at any age (esp 5-12months) * Intermittent inconsolable crying with drawing of legs up +- bilious vomiting * May have ‘redcurrant jam’ blood in nappy * Sausage shaped abdominal mass may be felt
32
What is seen on USS in intussusception?
Target sign
33
Treatment of intussusception
Reduction by air enema/balloon catheter under USS Fluid resuscitation Analgesia Antibiotics
34
Risk factors for intussusception?
More common in CF, HSP, lymphoma
35
What happens in midgut malrotation? Signs and symptoms?
* If gut is malrotated during embryonic development it is prone to undergo volvulus upon the mesentery. Superior mesenteric artery completely cut off. * Usually in neonatal period: green bilious vomit, distension, rectal bleeding
36
What is coeliac disease?
• IgA autoimmune systemic disorder of genetically susceptible individuals (eg HLA-DQ2-8) • Triggered and maintained by gluten 1/100 children
37
Signs of coeliac disease?
``` Largely distended abdomen, Weight loss/skeletal appearance after weening Flat buttocks Failure to thrive Abnormal stools ```
38
How is coeliac diagnosed?
Diagnosis by serology (IgA, EMA, TransGlutaminase) and histology (flattening of cilia, inflammation) Must be eating at least 2 portions a day of gluten for 4 months for these features to be seen. Diagnosis can also be a really high IgA and genetic testing.
39
Treatment of coeliac?
Gluten free diet for life (Wheat, rye, barley) Dietetic support
40
What is associated with coeliac disease?
Associated with other autoimmune disease (T1DM, thyroid disease) Secondary lactose intolerance
41
Inflammatory bowel disease signs and symptoms
Abdo pain, poor growth, delayed puberty, diarrhoea, rectal bleeding, pyoderma gangrenosum
42
Crohn's signs and symptoms
Oral ulcers, anorexia, anal fissures/fistulae, weight loss: | transmural
43
Ulcerative colitis signs and symptoms
Passage of mucus, urgency, bloody diarrhoea | Diffuse mucosal, uniform, continuous inflammation
44
Complications of Crohn's disease
Intestinal strictures Abscesses in the wall of the intestine or adjacent structures Fistulae Anaemia Malnutrition Colorectal and small bowel cancers Growth failure and delayed puberty in children
45
Extra-intestinal manifestations of Crohn's
Arthritis and abnormalities of the joints, eyes, liver and skin Secondary osteoporosis
46
Treatment of Crohn's
To induce remission: Oral steroids/budesonide Aminosalicylates (sulfasalazine and mesalazine) are less effective Azathioprine or mercaptopurine can be added MAB: adalimumab and infliximab if severe Maintenance: Azathioprine or mercaptopurine Loperamide hydrochloride or codeine phosphate for diarrhoea
47
Ulcerative colitis treatment
Chronic diarrhoea: loperamide hydrochloride or codeine phosphate Rectal aminosalicylate (mesalazine or sulfasalazine Add oral prednisolone if not improved MABs if not improved Acute severe: IV ciclosporin/infliximab IV hydrocortisone
48
Treatment of C.diff colitis
Metronidazole | Vancomycin
49
First line treatment in mod/severe constipation
Macrogol (eg laxido) osmotic laxative
50
What is the diagnosis of tinkling bowel sounds, swelling in testicle, cannot get above, doesn't transilluminate
An incarcerated inguinal hernia | Due to processus vaginalis (outpouching of peritoneum)
51
What are the 2 main types of malabsorption?
Due to lack of enzymes for breakdown of food (eg pancreatic insufficiency) Due to disruption of luminal border of gut
52
What can go wrong in the luminal phase to cause malabsorption?
``` Cofactor deficiency (eg pernicious anaemia) Lipid solubilisation (bile salt synthesis/cholestasis/bile salt loss) Defective nutrient hydrolysis (pancreatic enzymes, lipase activation, rapid transit of food) ```
53
Signs of malabsorption
* Weight loss/Failure to thrive * Abnormal diarrhoea/steatorrhoea/flatulence * Nutritional deficiency
54
Risk factors for malnutrition
Delayed or problematic progression of solids Early feeding difficulties (GORD, tube feeding) Poor appetite Dental problems Parents cultural attitude Behavioural difficulties /rigid parenting skills Parental (eg post-natal depression)
55
What can go wrong in the mucosal phase to cause malabsorption?
Extensive mucosal loss (resection/infarction) Diffuse mucosal disease (coeliac, Crohn's) Disease of enterocytes
56
What can go wrong in the transport phase to cause malabsorption?
Vascular (vasculitis, atheroma) | Lymphatic drainage
57
Most common cause of gastroenteritis in UK
Rotavirus
58
What metabolic issue can cause constipation?
Hypothyroidism
59
Name 4 pathogens that can cause bloody diarrhoea
Shigella, E.coli, salmonella, campylobacter
60
Name 4 signs of chronic liver disease in children
Bruising Clubbing Splenomegaly Encephalopathy
61
Difference between infant and adult inguinal hernias
Infant (always indirect, due to patent processus vaginalis) | Adult (indirect or direct, due to weakness in muscle of inguinal canal
62
Definition of hernia
Protrusion of a viscus or part of a viscus through the walls of its containing cavity into an abnormal position
63
Describe formation of congenital hernia
Patent processus vaginalis Processus vaginalis should obliterate following descent of the testes. If it stays patent it may fill with - Fluid → hydrocele - Bowel/omentum → indirect inguinal hernia
64
Describe an indirect inguinal hernia
 Emerge through deep ring, inguinal canal and superficial ring Intestinal loop within spermatic cord  Same 3 coverings as cord and descend into the scrotum  Can strangulate Herniating bowel passes lateral to inferior epigastric vessels Above and medial to pubic tubercle
65
Describe direct inguinal hernia
Acquired, older people Emerge through Hesselbach’s triangle, defect in posterior wall of inguinal canal (peritoneum and transversalis fascia) Herniating bowel passes medial to inferior epigastric vessels Rarely descend into scrotum Rarely strangulate Above and medial to pubic tubercle
66
Borders of hesselbach triangle
``` Inguinal ligament (inferiorly) Inferior epigastric vessels (superio-laterally) Rectus abdominis muscle (medially) ```
67
Where are femoral hernias?
Below inguinal ligament In femoral canal Below and lateral to pubic tubercle Medial to sartorius and femoral nerve and artery

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