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Flashcards in GI Deck (145):
1

What is pyloric stenosis

hypertrophy of the pyloric muscle causing gastric outlet obstruction

2

When does pyloric stenosis typically present?

at 2-7 weeks of age

3

In what gender is pyloric stenosis more common?

boys

4

What is a risk factor for pyloric stenosis?

fhx

5

What are the clinical features of pyloric stenosis?

vomiting - projectile
hunger after vomiting until dehydration leads to loss of interest in feeding
weight loss if delayed presentation
hypochloraemic metabolic alkalosis w low plasma sodium and potassium

6

What are the ix for pyloric stenosis?

test feed
gastric peristalsis
pyloric mass - feels like an olive in RUQ
US

7

What is the management of pyloric stenosis?

correct fluid and electrolytes - IV (0.45% saline and 5% dextrose w potassium)
Ramsteds pyloromyotomy

8

What is intussusception?

invagination of proximal bowel into distal segment

9

Where does intussusception most commonly occur?

ileocecal joint

10

What is the peak age of presentation of intussusception?

3m - 2yrs

11

What is a serious complication of intussusception ?

stretching and constriction of mesentery -> venous obstruction -> bleeding and engorgement from bowel mucosa, fluid loss and bowel perforation, peritonitis and gut necrosis

12

What are the signs/sx of intussusception ?

1. paroxysms of severe colicky pain
2. during episodes, go pale and draws up legs
3. vomiting (can be bile stained)
4. redcurrent jelly stool (late sign or during PR)
5. sausage shaped mass palpable

13

What are the ix for intussusception?

USS - may show target like mass

14

What is the management of intussusception?

Reduction by rectal air insufflation (unless peritonitis)
operative reduction (laparotomy)

15

Explain the pathophysiology of coeliac disease

1. Gliadin part of gluten provokes a damaging immunological response in the proximal small intestinal mucosa
2. There is rate of migration of enterocytes moving up the villi from the crypts but this is insufficient to compensate for cell loss from the villous tips
3. Villi become shorter and then absent (villous atrophy)
4. Mucosa becomes flat

16

What is the incidence of coeliac disease in children

1/100

17

What genes are associated w coeliac disease?

HLA-DQ2
HLA-DQ8

18

When does presentation of coeliac depend?

time child starts eating gluten

19

What is the typical presentation of coeliac disease

malabsorptive syndrome:
failure to thrive, weight loss
bloating
diarrhoea
anaemia

20

what are the clinical features of coeliac disease?

Highly variable including mild non-specific GI symptoms, anaemia and growth failure, arthralgia, short stature

21

What are the ix for coeliac disease

1. +ve IgA tissue transglutaminase abs
2. +ve endomysial abs
3. small bowel biopsy at endoscopy confirms

22

When is a gluten challenge indicated in ix for coeliac disease?

when biopsy is doubtful
response to gluten withdrawal is doubtful
<2yrs

23

What is the management of coeliac disease?

gluten free diet!!

24

What foods contain gluten?

wheat, barley, rye
bread, cake, pasta, pizza, pies

25

What foods don't contain gluten that are ok to eat?

rice
maize
soya
potato

26

What conditions is coeliac disease associated w?

T1DM
Hypothyroidism

27

What is the prognosis of coeliac disease?

good if gluten free diet adhered to
increased risk of small bowel malignancy if not adhered to

28

What are common causes of abdominal pain?

gastroenteritis
UTI
Viral illness
appendicitis

29

What is hard faeces a sign of?

constipation

30

In children of African or mediterranean decent w abdominal pain, what is important to consideR?

sickle cell disease

31

What test is important if you suspect TB in abdominal pain?

tuberculin test

32

What is pica and what is important to test for this?

eating non-food items
blood lead level and ferritin

33

What does periodic abdominal pain w vomiting pointt to?

abdo migraine

34

Abdominal pain in the presence of past UTIs points to what?

GU disease e.g renal colic

35

What are important investigations for abdominal pain?

1. urine dip - diabetes, UTI
2. AXR
3. US, FBC, CRP, renal imaging, barium studies

36

What are some rarer causes of abdominal pain?

Mumps
Pancreatitis
Diabetes
Volvulus
Intussusception
Meckel’s diverticulum
Peptic ulcer
Crohns/UC
Hirschsprung’s disease
Henoch-Schönlein purpura
Hydronephrosis

37

What cause of abdominal pain is important to rule out in boys?

testicular torsion

38

What causes of abdominal pain are important to consider in older girls?

menstruation
PID

39

What are some extra-abdominal causes of abdominal pain?

Upper RTI
Lower lobe pneumonia
Testicular torsion

40

What age is appendicitis not usually seen?

under 5yo

41

What are the sx of appendicitis?

− Anorexia
− Vomiting (minimal)
− Abdo pain, initially central and colicky but then localising to RIF
− Flushed face with oral fetor (strong foul smell)

42

What are the signs of appendicitis?

low grade fever (37.2-38)
Abdo pain aggravated by movement
Persistent tenderness, guarding in RIF (McBurney's point)

43

What is McBurney's point?

Most common location of the base of the appendix where it is attached to the caecum

44

How does appendicitis in preschool children tend to present?

faecoliths seen on AXR
Rapid perforation as omentum less well developed and fails to surround appendix

45

What is a faecolith

hard discrete mass of thickened faeces

46

What are the investigations for appendicitis?

US may support diagnosis
many tests aren't useful

47

What are the complications of appendicitis?

abscess
perforation

48

What is the management of uncomplicated appendicitis?

appendicectomy

49

What is complicated appendicitis?

appendicitis + complications (perforation, appendix mass, abscess)

50

What is the management of complicated appendicitis?

fluids, IV abx, laparotomy to remove appendix

51

what age is Gastro-oesophageal reflux common and why?

infancy
inappropriate relaxation of the LOS due to functional immaturity

52

what are the risk factors for Gastro-oesophageal reflux

fluid diet
horizontal posture
short intra-abdominal length

53

How does Gastro-oesophageal reflux usually present?

recurrent regurgitation
distress after feeds
child is usually well and putting on weight

54

In who is severe gastro-oesophageal reflux common in?

cerebral palsy
preterm
following surgery for oesophageal atresia or diaphragmatic hernia

55

What are the complications of gastro-oesophageal reflux?

failure to thrive -severe vomiting
oesophagitis - haematemesis, discomfort on feeding, anaemia
pneumonia - due to recurrent aspiration

56

What are the ix for gastro-oesophageal reflux?

USUALLY CLINICAL
24h oesophageal pH monitoring to quantify degree of reflux
endoscopy w oesophageal biopsy

57

What is the management of gastro-oesophageal reflux?

1. thickening agents to feeds
2. position 30 degree head up
3. avoid overfeeding
4. alginate therapy

58

What treatment may be needed in severe gastro-oesophageal reflux?

PPI - omeprazole
H2 receptor antagonist - ranitidine
Domperidone to enhance gastric emptying

59

what is a differential of gastro oesophageal reflux?

cows milk protein intolerance if vomitign

60

What is the treatment of gastro-oesophageal reflux that is either complicated or due to oesophageal strictures?

surgical
Nissen fundoplication

61

What is a typical presentation of toddler diarrhoea?

stools of varying consistency
undigested veg in stools
well and thriving w no precipitating dietary factors

62

What is the management of toddler diarrhoea?

Usually none - most grow out by 5yrs
Diet adequate in fat relieves sx (slows gut transit)
reduce fresh fruit juice, can exacerbate

63

What should you consider in a child failing to thrive w chronic diarrhoea?

coeliac disease
cow's milk protein intolerance

64

What should you consider in a child w chronic diarrhoea following gastroenteritis?

post-gastroenteritis syndrome and associated temporary lactose intolerance

65

what is the most common cause of chronic diarrhoea in the developed world?

cows milk protein intolerance

66

What motility disorders cause increased stool in diarrhoea?

thyrotoxicosis
IBS
dumping syndrome

67

What motility disorders cause decreased stool in diarrhoea?

pseudo-obstruction
intussusception

68

What are inflammatory causes of diarrhoea? (bloody)

Infectious: shigella, salmonella, rotavirus, campylobacter, Crohn's/UC, coeliac, haemolytic uraemia syndrome

69

What are causes of watery stools in diarrhoea?

Cholera
c.diff
ecoli

70

What is the most common cause of gastroenteritis?

rotavirus

71

What are the features of gastroenteritis?

loose or water stools (sudden)
vomiting
contact w person w D&V
travel abroad?

72

What is a major complication of gastroenteritis?

dehydration

73

what is the treatment of gastroenteritis w no dehydration?

prevent dehydration
continue breast feeding
encourage fluids
oral rehydration therapy (dioralyte)
no fruit juice

74

What is clinical dehydration defined as?

5-10% loss of body weight

75

what is shock defined as in dehydration?

>10% loss of body weight

76

What are red flag sins of clinical dehydration

unwell/deteriorating
altered responsiveness
sunken eyes
tachycardia
tachypnoea
reduced skin turgor

77

What are the ix in dehydration?

usually none
stool culture?

78

what is the rx of clinical dehydration

ORS
fluid deficit replacement (50ml/kg) + maintenance fluid
continue breastfeeding
NG tube if vomiting or inadequate fluid intake

79

What is the rx of shock in dehydration?

IV therapy
rapid infusion of 0.9% NaCl solution

80

Explain IV therapy for rehydration

replace fluid deficit + maintenance fluids
give 0.9% NaCl +/- 5% glucose
maybe K+ supplementation

81

What is important to avoid when dehydrated?

fruit juices
carbonated drinks

82

How is post-gastroenteritis syndrome confirmed:

presence of non-absorbed sugar in stools - +ve clinitest result

83

What is post-gastroenteritis syndrome?

intro of normal diet making watery diarrhoea return

84

What is the management of post-gastroenteritis syndrome?

ORS for 24hr

85

What is the classical presentation of crohns?

growth failure
delayed puberty
abdo pain
diarrhoea
weight loss
general: fever, lethargy

86

What are the extra-intestinal manifestations of crohns

oral lesions
perianal skin tags
uveitis
arthralgia
erythema nodosum

87

How is a diagnosis of crohns made?

raised platelets, ESR, CRP
Iron deficiency anaemia
low serum albumin
DEFINITIVE: endoscopy w biopsy - non-caseatig epithelioid cell granulomata + fissuring, narrowing mucosal irregularities and bowel wall thickening

88

What is the pharmacological management of crohns?

1. immunosuppressants: azathioprine, methotrexate
2. Ant-TNF agents - infliximab, adalimumab
3. Supplemental enteral nutrition for growth failure

89

When is surgery necessary in crohns?

obstruction
fistulae
abscess formation
severe localised disease unresponsive to medical treatment

90

What is the presentation of UC?

Rectal bleeding
Diarrhoea
Colicky pain

91

What features are more common in crohns than UC?

weight loss and growth failure

92

What are the extraintestinal manifestations of UC?

erythema nodosum
arthritis

93

What is pancolitis?

UC spread throughout entire length of colon

94

How is a diagnosis of UC made?

endoscopy and biopsy
there is:
mucosal inflammation
crypt damage
ulceration

95

What is the management of uC?

1. aminosalicylates - balsazide, mesalazine (induction and maintenance therapy)
2. systemic steroids (azathioprine) for aggressive disease

96

What is a complication of UC?

severe fulminating disease

97

What is the treatment of the serious complication of UC?

IV fluids
steroids
Ciclosporin (if above 2 fail)

98

What malignancy are adults w UC at risk of?

adenocarcinoma of the colon

99

What is the rx of UC confined to the rectum and sigmoid colon?

topical steroids

100

What is the difference between Crohn's and UC regarding what part of the GI tract is affected?

Crohns - ANY part, oral and perianal disease
UC - only colon, starts in rectum, extends proximally

101

What is the difference between Crohn's and UC regarding involvement

Crohns - skip lesions
UC - continuous involvement

102

What is the difference between Crohn's and UC regarding the mucosa?

Crohns has deep ulcers and fissures, cobblestone
UC - red mucosa, bleeds easily, ulcers and pseudopolyps

103

What is the difference between Crohn's and UC regarding which parts of the GI wall are inflamed?

Crohns - transmural
UC - mucosal

104

What is the difference between Crohn's and UC regarding histology?

Crohns - granulomas
UC - no granulomata, goblet cell depletion, crypt abscesses

105

What is Hirschsprung's disease?

absence of the myenteric nerve plexus (Auerbach and Meissner) in the rectum which may extend along the colon

106

How does Hirschsprung's disease present?

- no passage of meconium w/in 48h of birth and the abdomen distends
- older children: constipation, abdominal distension

107

What is Hirschsprung's disease associated w?

Down's syndrome
3x more common in males

108

How does Hirschsprung's disease present?

- no passage of meconium w/in 48h of birth and the abdomen distends
- older children: constipation, abdominal distension

109

What is Hirschsprung's disease associated w?

Down's syndrome
3x more common in males

110

What are features suggesting hyponatraemic dehydration

jittery movements
increased muscle tone
hyperreflexia
convulsions
drowsiness or coma

111

What children are at increased risk of dehydration?

children <1y
low birthweight infants
6 or more diarrhoeal stools in past 24hrs
vomited 3 or more times in past 24hrs
sx of malnutrition
stopped breastfeeding during illness

112

What is posseting?

effortless regurgitation of milk
common

113

What are the main causes of vomiting?

posseting
between feeds
GOR
gastritis/gastroenteritis
Overfeeding
pyloric stenosis
infections
adverse food reactions

114

What causes bile-stained vomit?

intestinal obstruction
duodenal or volvulus

115

What causes haematemesis?

oesophagitis
peptic ulcer
oral/nasal bleeding

116

What are the causes of bloody stools?

intussusception
gastroenteritis - campylobacter or salmonella

117

What are the causes of severe dehydration/shock

severe gastroenteritis
systemic infection
DKA

118

What are causes of failure to thrive?

GOR
Coeliac

119

What are causes of abode distension?

obstruction

120

What is the cause of vomiting at the end of paroxysmal coughing?

whooping cough

121

what are the different causes of intestinal obstruction?

pyloric stenosis
atresia
intussusception
malrotation
volvulus
strangulated inguinal hernia
hirschsprungs
adhesions
foreign body

122

When should diarrhoea be investigated in a child?

Septicaemia is suspected.
There is blood and/or mucus in the stool.
The child is immunocompromised.
The child has recently been abroad.
The diarrhoea has not improved by day 7.
There is uncertainty about the diagnosis of gastroenteritis.

123

What is Meckel's diverticulum?

vestigial remnant of the Vitelline duct

124

How does meckels diverticulum present

Most asymptomatic
May present w:
− Severe rectal bleeding
− Intussusception
− Volvulus
− Diverticulitis

125

How is meckel's diverticulum diagnosed?

Technetium scan

126

What is the treatment of meckel's diverticulum?

surgical resection

127

What is the average frequency of stools in the 1st week of life?

4 a day

128

What is the average frequency of stools at 1yr age?

2 a day

129

What is average frequency of stool by 4yrs of age?

3 per day to 3 a week

130

What are causes of constipation?

Mostly idiopathic!
Dehydration
Low-fibre diet
Meds e.g. opiates
anal fissure
potty training gone wrong
hypothyroidism, hypercalcaemia
Hirschsprung
LDs

131

What are Ix for constipation?

examination - palpable abdo mass
DRE if pathological cause suspected

132

what does failure to pass meconium in the first 24hrs of life indicate?

Hirschsprung disease

133

What does failure to thrive and constipation indicate?

hypothyroidism
coeliac
hirschsprung

134

What does perianal fistulae, abscesses or issues indicated with constipation?

perianal crohns

135

why does constipation and diarrhoea occur at the same time?

when constipation is long standing
the rectum becomes overdistended and there is a loss in the feeling/need to defecate so there is involuntary soiling as contractions of the full rectum inhibit the internal sphincter leading to overflow

136

Give then management of constipation

1. macrogol laxative - movicol
2. stimulant laxative (Senna)
3. +/- osmotic laxative - lactulose
4. enema or manual evacuation

137

When should constipation be suspected?

2 or more of the following clinical features:
1. fewer than 3 complete stools per week
2. hard, large stool
3. 'rabbit droppings' stool
4. overflow soiling in older 1yrs

138

when should faecal impaction be suspected?

1. hx of severe sx of constiopation
2. overflow soiling
3. faecal mass palpable on abdominal examination

139

What are behavioural interventions for constipation?

scheduled toileting
bowel habit diary
reward systems

140

what are complications of idiopathic constipation?

anal fissure
haemorrhoids
rectal prolapse
megarectum
faecal impaction and soiling
volvulus
distress

141

give red flags of constipation that indicate hirschsprungs

sx of constipation from brith or first few weeks of life
delay in passing meconium for more Han 48hrs after birth
abdo distension w vomiting
FHx

142

Give a red flag of constipation that may indicate CF

Delay in passing meconium for more than 48h after birth

143

what does ribbon stool pattern in constipation indicate?

anal sphincter stenosis

144

give red flag sx of constipation that hint at neurological problems

Leg weakness/ motor delay - spinal cord abnormality
abnormalities in gluteal muscles

145

Give amber flags of constipation

faltered growth (systemic)
constipation triggered by intro of cows milk
poss child maltreatment