GI

Question 1

What are the differential diagnoses for vomiting?

Answer 1

Gastroesophageal reflux
Overfeeding
Pyloric stenosis
Cow’s milk allergy

Question 2

What are the symptoms of pyloric stenosis?

Answer 2

Vomiting - non-bilious, large volume, not keeping down feeds
Irritable and crying
Not gaining weight adequately
On examination - looks slightly dehydrated
Visible gastric peristalsis

Question 3

What investigations would be done if pyloric stenosis was suspected?

Answer 3

Test feed
Ultrasound - see stenosed pyloric sphincter
Blood gases - high pH (metabolic alkalosis), low Cl and K

Question 4

How is pyloric stenosis managed?

Answer 4

Fluid resuscitation

Refer to surgeons - ramstedts pyloromyotomy

Question 5

What is bilious vomiting?

Answer 5

Green vomit

ALARM BELLS

Question 6

What are the causes of bilious vomiting?

Answer 6

Intestinal obstruction until proven otherwise
Intestinal atresia - only in new borns
Malrotation
Ileus
Crohn's disease with strictures

Question 7

What investigations would be done if bilious vomiting was suspected?

Answer 7

Abdominal x-ray
Consider contrast meal
Surgical opinion

Question 8

How is bilious vomiting treated?

Answer 8

Nil by mouth
IV fluids
Surgical opinion

Question 9

What are the causes of effortless vomiting?

Answer 9

GORD - LOS problem

Question 10

What are the symptoms of effortless vomiting?

Answer 10

Vomiting
Haematemesis
Feeding problems
Failure to thrive
Apnoea
Cough
Wheeze
Chest infections

Question 11

How is effortless vomiting investigated?

Answer 11

History and examination usually enough
Radiological - video fluoroscopy, barium swallow
pH study
Oesophageal impedance monitoring
Endoscopy if severe

Question 12

How is effortless vomiting treated?

Answer 12

Feeding advice - thickeners, feeding position, behavioural problem
Nutritional support - calorie supplements, try dairy free milk, NG tube, gastrostomy
Medical - feed thickener (gaviscon), pro kinetic drugs, acid suppressing drugs (PPIs)
Surgery

Question 13

What is the definition of chronic diarrhoea?

Answer 13

4 or more stools per day
Acute diarrhoea <1 week
Persistent diarrhoea - 2-4 weeks
Chronic diarrhoea > 4 weeks

Question 14

What are the causes of chronic diarrhoea?

Answer 14

Motility disturbance - toddler diarrhoea, IBS
Active secretion (secretory) - acute infective diarrhoea (cholera), IBD
Malabsorption of nutrients (osmotic) - food allergy, coeliac disease, CF

Question 15

What are the types of chronic diarrhoea?

Answer 15

Osmotic
Secretory
Motility
Inflammatory

Question 16

Osmotic diarrhoea

Answer 16

Movement of water into the bowel to equilibrate osmotic gradient
Usually a feature of malabsorption
Clinical remission with removal of causative agent
Stool - small volumes, stops when fasting

Question 17

Secretory diarrhoea

Answer 17

Associated with toxin production - vibrio cholera, enterotoxigenic Escherichia coli
Intestinal fluid secretion is driven by active Cl- secretion (and therefore water) via CFTR
Stool - large volume, diarrhoea continues with fasting

Question 18

Inflammatory diarrhoea

Answer 18

Malabsorption due to intestinal change
Secretory effect of cytokines
Accelerated transit time in response to inflammation
Protein exudate across inflamed epithelium

Question 19

Where is fat malabsorption seen?

Answer 19

Pancreatic disease - diarrhoea due to lack of lipase and resultant steoatorrhea
Hepatobiliary disease - chronic liver disease, cholsetasis

Question 20

Coeliac disease

Answer 20

Sensitivity to gluten

Autoimmune condition - antibodies form against gluten, complexes form when gluten that attack the small bowel

Question 21

Coeliac disease - genetic susceptibility

Answer 21

HLA DQ2 and DQ8

Question 22

What are the symptoms of coeliac disease?

Answer 22

Abdominal bloating
Diarrhoea
Failure to thrive
Short stature
Constipation - maybe
Tiredness
Dermatitis herpetiformit

Question 23

How is coeliac disease investigated?

Answer 23

Serological screens - anti-tissue transglutaminase, anti-endomysial, IgA testing
Duodenal biopsy - don’t need
Genetic testing

Question 24

How is coeliac disease treated?

Answer 24

Gluten-free diet for life

Question 25

What are the symptoms of constipation?

Answer 25

``` Poor appetite Irritability Lack of energy Abdominal pain or distension Withholding or straining Can have diarrhoea ```

Question 26

Why do children become constipated?

Answer 26

Social – poor diet (insufficient fluids, excessive milk), potty training/school toilet Physical – intercurrent illness, medication Family history Psychological – secondary Organic

Question 27

What is the cycle of constipation?

Answer 27

Pain or anal fissure Withholding of stool – the longer the stool stays in the colon the drier it gets so the harder it will be to pass Constipation Large hard stool

Question 28

How is constipation treated?

Answer 28

Explain treatments to parents Dietary - increase fruit and fibre, decrease milk Psychological - make going to the toilet pleasant, reward good behaviour Movicol - isotonic laxative Lactulose - osmotic laxative

Question 29

How is impactation treated?

Answer 29

Empty impacted rectum Empty colon Maintain regular stool passage Slow weaning off treatment

Question 30

What are the symptoms of Crohn's disease?

Answer 30

``` Weight loss Growth failure Abdominal pain Diarrhoea Rectal bleeding Arthritis Mass ```

Question 31

How is Crohn's disease treated?

Answer 31

Induce remission – nutritional therapy, steroids Maintain remission – thiopurines Step-up therapy – anti-TNF Surgery – only for complications, not curative

Question 32

What are the symptoms of ulcerative colitis?

Answer 32

Diarrhoea Rectal bleeding Abdominal pain Less systemic symptoms

Question 33

How is ulcerative colitis treated?

Answer 33

Induce remission – 5-ASA, steroids Maintain remission – 5-ASA, thiopurines Step-up therapy – anti-TNF Surgery – for failure to respond to medical therapy, curative

Question 34

How is IBD investigated?

Answer 34

Stool calprotectin FBC & ESR – anaemia, thrombocytosis, raised ESR Biochemistry – raised CRP, low albumin Microbiology – no stool pathogens Definitive - MRI, barium meal, endoscopy (any kind)

Question 35

If an infant had a cow's milk allergy, what milk would you recommend?

Answer 35

Nutramigen - extensively hydrolysed protein feeds