Red flags in constipation and soiling
Failure to pass meconium within 24hrs FTT, gross abdo distension Spinal pathology Bilious vomiting Abnormal anal patency
Management of constipation
Diet - increase hydration + fibre
Behaviour - toilet footrest, start charts
Movicol paediatric plain - treatment for at least 3 months. Dont stop immediately - want a prolonged period of good bowel habit, to allow baggy bowel to recover
Management of Viral/Bacterial gastroenteritis
Oral rehydration solution (ORS) - Dont prescribe anti-diarrhoeals - can give NG tube if not tolerated PO
Give fluid deficit replacement (50 x Bodyweight)/4hrs
+
Maintenance fluid replacement
Most common causes of viral and bacterial gastroenteritis
Viral - rotavirus, adenovirus, astrovirus
Bacterial - salmonella, campylobacter, shigella, E.coli, C.diff, vibrio cholerae
Clinical features of GOR and GORD
GOR - effortless regurgitation of milk/gastric contents (posset). Not active process, no contraction of abdominal muscles
GORD - GOR but with complications - FTT, LRTI, aspiration, choking, apnoea, hoarsenss
Management of GORD/GOR
Review feeding technique - keep upright immediately after feeds/smaller volumes
Thickened formula - Enfamil, SMA Staydown - for 6 months MAX
Dont routinely offer antacids/PPI
What constitutes recurrent abdominal pain, and what are some investigations?
2+ discrete episodes in a 3 month period
Abdo USS/Xray, faecal calprotectin, 13C breath test for H pylori. IgA - tTG (coeliac)
Investigations and management of Appendicitis
FBC - leukocytosis, Abdo/pelvic CT scan
Appendectomy, + broad spec Abx if peritonitis/perf
Presentation of coeliac disease
Persistent GI symptoms - diarrhoea, pain, bloating
Fatigue, FTT
severe persistent mouth ulcers
Unexplained iron, vitamin B12, or folate deficiency
Associated with dermatitis herpetiformis
Investigations in coeliac disease
IgA-tTG (tissue transglutaminase)
HOWEVER - must be on a gluten diet - for at least 3 months in order to register positive diagnostic test
Bowel biopsy - showing chronic villous atrophy, crypt hyperplasia —> remission on exclusion of gluten
How much should babies feed - Amounts
0-6 weeks - 150ml/Kg
6 weeks - 4 months - 150ml/Kg
4 - 6 months - 150ml/Kg
6+ months - 120ml/Kg
Conversion between mL to Ounce
1 ounce = 30 (~28) mL
Pattern of weight gain for babies?
0-3 months = 200g / week
3-6 months = 150g / week
6-9 months = 100g / week
9-12 months = 75g / week
Presentation of an inguinal hernia
Direct v indirect Commonly in R groin Intermittent lump in groin/scrotum - present on crying/ straining May be irreducible Can't get above lump
Management of inguinal hernia
Surgical - due to risk of strangulation
High risk if cant reduce at all
Pathological predisposition to intussusception
Usually following viral illness
Immature, enlarged peyer’s patches (lymphoid tissue in bowel) –> invagination of bowel and obstruction
Clinical features of intussusception
acute onset, colicky pain Early vomiting, rapidly becoming bilious Sausage shaped mass, usually in RUQ strawberry current (bloody stool) Absence of lower bowel signs
Investigation in intussusception
Abdo USS - Doughnut, or Target sign
AXR - dilated bowel loops
Management of intussusception
Drip + suck - to remove pooled fluid from gut
Air enema to reduce bowel
Failing that - laparotomy
Causes of jaundice?
Serum Bilirubin >25-30 mmol/L
Unconjugated - haemolysis, Gilberts, G6PD
Conjugated - cirrhosis, post-hepatic obstruction e.g. biliary atresia, choledochal cyst
What is mesenteric adenitis
Non-specific abdo pain, lasting 24-48hrs
Following infection, commonly strep throat
Inflammation of lymphoid tissue within mesentery
Investigations in pyloric stenosis?
Serum electrolytes - may show hypochloraemic alkalosis +- a mild hypokalaemia
USS pylorus - shows thickened sphincter, ^ canal length
Management of pyloric stenosis
correct fluid/electrolyte imbalance
Ramstedt’s pyloromyotomy
Different types of undescended testicle?
Anorchidism - no testicle there
Retractile - exaggerated cremasteric reflex
Ascending - short spermatic cord (later presentation)
Testicular maldescent - arrested (usually in inguinal canal, or ectopic (in suprainguinal pouch)
management of undescended testicle
If not descended by 6 months, investigate
If continues, surgical correction - orchidopexy - by 12 months
Presentation of biliary atresia?
Persistent jaundice, shortly after birth
Pale stool, dark urine
Splenomegaly due to portal hypertension
jaundice lasting >14 days - BA must be investigated
Investigations in biliary atresia
serum and total bilirubin
PT, and INR with be ^^
Serum AST/ALT, ALP and gamma GT ^^
USS - hepatobiliary scintigraphy
Management of biliary atresia
Kasai - portoenterostomy
Ursodeoxychloric acid to encourage bile flow
2nd line - liver transplantation
What are HBsAG and Anti-HBs
HBs = Hep B surface antigen - indicates active acute/chronic infection
Anti-HBs = anti- Hep B surface antigen = indicates resolved infection / prior vaccination
What are Anti-HBc - IgM and IgG
IgM - anti - Hep B core antibodies - appear first during acute infection
IgG - appear later - during resolved acute infection/chronic - but not after vaccination
Difference between Hep A and Hep B
Hep A - faecal oral transmission. mild illness lasting 2-4 weeks. can be re-infected in future
Hep B - often transmitted vertically from mother. Often chronic carriers.
Clinical features of Hirschprung’s disease
Aganglionic bowel - lacking parasympathetic nerve cells –> severe constriction
Failure to pass meconium in first 48hrs of life + vomiting
This is a GI emergency
Investigations and management in Hirschprung’s
Bowel biopsy is diagnostic
Consider barium enema studies
Surgical - anorectal pull through - removal of aganglionic bowel - maybe stoma until older
Investigations and management of IBD
Fecal calprotectin. Endoscopy/colonoscopy for diagnosis
Induce remission with Liquid diet for 6 weeks, or steroids (pred)
+ DMARDS - Azathioprine, methotrexate, infliximab, mesalazine
What is toddlers diarrhoea?
Fast transit - through immature gut
Diarrhoea with undigested food - however children usually well and thriving
Most children grow out of it by age 5
What is volvulus
Twisting of the small bowel around axis of the superior mesenteric artery
- severe obstruction +- ischaemia - GI emergency
Requires urgent laparotomy, correction (remove appendix while youre at it)