GI Disorders in Paeds Flashcards
(141 cards)
1
Q
A 6 month old boy presents to clinic with chronic constipation and abdominal distension.
What do we want to know from PMHx?
A
- Neonatal period - when was meconium first passed?
- Do they have Down’s syndrome?
- How are they getting on with toilet training? (more older child)
- Diet/exercise? (more relevant in older child)
- Any neurological conditions?
2
Q
Why is when meconium was first passed a relevant question in constipation?
A
If they failed to pass any within 48 hours of birth, Hirschsprung’s disease may be the cause.
3
Q
What is Hirschsprung’s disease?
A
Absence of parasympathetic ganglion cells in gut, usually in rectum, but may extend into colon -> segments of bowel unable to relax -> functional obstruction.
4
Q
How can we diagnose Hirschsprung’s disease?
A
- Clinical diagnosis
- AXR shows distal intestinal obstruction
- Rectal biopsy shows no ganglion cells in submucosa
5
Q
How do we manage Hirschsprung’s disease?
A
Surgically - single stage pull through now, or traditional 3 stage procedure (defunctioning colostomy, pull through procedure, and closure of colostomy)
6
Q
What % of children with Hirschsprung’s disease have good outcome?
A
75% get normal bowel control.
20% get partial bowel control.
7
Q
What is the most important complication of Hirschsprung’s disease? Why?
A
Enterocolitis - it has a 10% mortality
8
Q
A neonate is examined, and found to have jaundice.
What is our first step to getting a diagnosis?
A
Establish if it is conjugated or unconjugated bilirubin
9
Q
A child is brought in with “colicky pains”.
What is colic?
A
An intermittent pain appearing to come from the abdomen that causes babies to cry periodically throughout the day.
10
Q
What causes baby colic?
A
Unknown in cause
11
Q
A child comes to the GP with their mother because she has noticed her child is not growing very much. After looking in the growth chart, you are also concerned.
What causes of failure to thrive can you think of?
Use a systematic approach.
A
V - hereditary spherocytosis, thalassaemia
I - IBD, bronchiectasis
T - Child abuse
A - Coeliac disease, hypothyroidism
M - metabolic disease e.g mitochondrial, inborn errors of metabolism
I - Immune deficiency, cow’s milk protein allergy
N
D
I
C/G - ToF, VSD
Other - GORD, CF
12
Q
What is baby colic defined as?
A
Distress or crying in an infant which lasts for more than 3 hours a day, more than 3 days a week, for at least 3 weeks in an otherwise healthy infant.
13
Q
How common is baby colic?
A
Occurs in 10-30% of infants, affecting male and female equally, and breast-fed and formulla-fed infants equally.
14
Q
What are some of the risk factors for baby colic?
A
Smoking/nicotine replacement in pregnancy
Preterm infants
SGA infants
15
Q
How does baby colic present?
A
Inconsolable crying, drawing knees up to chest, flatus, and redness of the face.
16
Q
What elements of a hx of baby colic are important to establish?
A
- Feeding - breast or bottle
- Weight gain
- Bowel habit
- Vomiting or reflux
- Timing of crying
- Duration of crying
17
Q
With an acute hx of baby colic, what differentials are there?
A
- Physical discomfort (cold, wet, hungry)
- Severe nappy rash
- Corneal abrasian
- Intussusception
- Volvulus
- Strangulated hernia
- Testicular torsion
- Non-accidental injury
18
Q
With an chronic hx of baby colic, what differentials are there?
A
- Reflux oesophagitis
- Lactose intolerance
- Constipation
- Cow’s milk protein allergy
- Parenting skills/experience of parents
19
Q
What investigations need to be done for baby colic?
A
Weight should be checked (normal weight gain is typical for these infants) by hx and examination should be enough.
20
Q
What S+S would make you suspect another differential for baby colic?
A
Signs like abnormal weight gain, failure to thrive, or other atypical symptoms.
21
Q
How are the majority of cases of baby colic managed?
A
Simple reassurance.
22
Q
If food intolerance is suspected with baby colic, how can it be managed?
A
Advise a hypoallergenic diet trial to help identify the allergen.
e.g. cow’s milk protein allergy -> trial completely hydrolysed formula.
23
Q
Are there any drugs recommended to help with baby colic?
A
No - simeticone or dicyclomine hydrochloride have no evidence but are unlikely to be harmful.
24
Q
What is the prognosis like for baby colic?
A
Excellent - most recover by 3-4 months, even though it is frustrating while it is going on.
25
How common is constipation in children?
Very - 10-30% of children are affected. It accounts for about 25% of paediatric GI work.
26
What definitions can be used for constipation in children?
Infrequent defecation, painful defecation, or both.
27
How infrequent is infrequent defecation?
Fewer than 3 bowel movements per week.
28
What behaviours might children exhibit when they are constipated?
Retentive posturing
| Withholding behaviours
29
What can chronic constipation cause?
Overflow incontinence i.e. passage of stools in inappropriate places following a period of constipation.
30
How common is function constipation in children?
90-95% of constipation is functional.
31
What is functional constipation?
Constipation that does not have a physical or physiological cause. The cause is often psychological, psychosomatic, or neurological.
32
What social or psychological issues might a child be going through causing constipation?
Bullying
Parental divorce
Sexual abuse
Exam stress
33
What needs to be asked in a constipation HPC?
- Frequency of defecation
- Consistency of stools
- Episodes of incontinence
- Pain on defecation
- Whether poo block toilet
- Associated behaviours
34
What can help identify the consistency of a stool from a child?
A visual aid = Bristol Stool Chart
35
What is pain on defecation likely to lead to?
Withholding
36
What should be looked for on examination of a child with constipation?
- Abdominal faecal mass
- Inspect of anal stenosis or ectopia
- Sacral abnormalities
37
Is a rectal examination usually done on a child?
No - it is not necessary and would be too traumatic for a child.
38
Suggest some organic causes of constipation.
- Anorectal malformations
- Anal fissure
- Rectal prolapse
- Hirschsprung's (very rarely presents late)
- Neuroenteric problems
- Spinal cord problems
- Metabolic (hypothyroid, coeliac, hypocalcaemia, CF)
- Toxins
- Cow's milk allergy
39
In a child under 1 year, how can a diagnosis of constipation be made?
Based on the following criteria - at least 2 of:
- Fewer than 3 complete stools in a week
- Hard rabbit-dropping stools
- Symptoms on defecation
- PMH of constipation
- Previous/current anal fissure
40
What amber flags may present with constipation?
Faltering growth
| Signs of possible maltreatment
41
What red flags may present with constipation?
- Symptoms start in neonatal period
- Failed/delayed passage of meconium
- Ribbon stools
- Lower neurological signs
- Abdo distension + vomiting
- Abnormalities found on examination
42
What triggers might be identifiable for constipation?
Weaning
Poor fluid intake
New school
Family problems
43
How long can constipation treatment take to fully work?
It may take months, especially if there is a behavioural aspect
44
What are the principles of treating simple constipation in children?
- Reassure
- Lifestyle changes
- Disimpaction
- Maintenance
- Refer if no response after 3 months
45
What lifestyle advice is given to help treat constipation?
Plenty of fluid, fibre, and exercise.
46
If an amber flag is present in a hx of constipation, how should it be managed?
-If there is evidence of faltering growth, treat for constipation and test for coeliac disease and hypothyroidism.
-If there is evidence of possible child maltreatment, treat for constipation and refer to guidelines on
suspected child abuse.
47
If a red flag is present in a hx of constipation, how should it be managed?
Refer immediately for specialist diagnosis and treatment. Do not treat the constipation in primary care.
48
What issues may need to be targeted when treating functional constipation?
- Anxiety
- Attitudes of guilt or blame
- Inappropriate coercive toilet training
- Social consequences e.g. of foecal incontinence in older children.
49
How should disimpaction be achieved?
-Use an osmotic laxative initially e.g. Movicol, lactulose
-Adjust the dose as appropriate
-If not tolerated, use stimulant laxative e.g. sodium picosulphate, senna
+\- lactulose or faecal softener e.g. docusate
50
What are the osmotic laxatives?
Movicol (polyethylene glycol)
| Lactulose
51
What are the stimulant laxatives?
Sodium picosulphate
Senna
Bisacodyl
52
What are the faecal softeners used in children?
Docusate
53
How often should a child be monitored when treating for disimpaction of constipation?
At least weekly until sucessful
54
What management is there for constipation maintenance therapy?
- Dietary advice about fibre and fluids
- Regular osmotic laxative to maintain soft stool
- Use of stimulant laxatives intermittently to avoid imoaction
55
What are osmotic laxatives preferred to stimulants for maintenance therapy for constipation?
Stimulant laxatives long term cause atonic colon and hypokalaemia
56
What behaviours should be encouraged in children to help prevent constipation?
- Regular, unhurried toileting
- Reward systems for using the toilet successfully
- Linking diary to reward system
57
What makes pain on passage of stools more likely?
Infrequent defecation
58
What can chronic constipation with obstruction lead to?
Enlarged rectum -> megarectum -> impaired sensation and decreased contractility -> soiling.
59
Are relapses of constipation common?
Yes - treat with an early increased dose of laxative
60
What complications can arise from constipation in children?
- Faecal impaction
- Chronic constipation
- Megacolon
- Rectal prolapse
- Anal fissure
- Faecal soiling
- Psychological effects
61
What is the prognosis associated with contipation in children?
50% resolve by a year
| 70% resolve by 2 years
62
What are most cases of gastroenteritis in children caused by?
Viral infection
63
How common is gastroenteritis in children?
Very - most children have at least one episode per year.
64
Which virus is most commonly found to cause gastroenteritis in children?
Rotavirus
65
What risk factors are there for increased incidence of gastroenteritis in a child?
- Immunocompromise
- Poor hygiene and lack of sanitation
- Poorly cooked or stored food
66
How does gastroenteritis most commonly present?
Sudden change in stool consistency/diarrhoea
May or may not have associated vomiting
Fever
67
If a child with gastroenteritis has recently had a course of antibiotics, what might the cause of the gastroenteritis be?
Clostridium difficile
68
A child is brought into A+E with acute bloody diarrhoea. If this is gastroenteritis, what is the most common cause (for bloody stools)?
Campylobacter species
69
What is the most worrying cause of bloody diarrhoea, especially if a child has recently come here from Africa?
Ebola, bu other features will be present
70
What other features of ebola are there other than blood diarrhoea?
```
Fever
Severe headache
Muscle pain
Weakness
Diarrhoea
Vomiting
Abdo pain
Lack of appetite
Unexplained bleeding or bruising
```
71
What main complication should a child with gastroenteritis be assessed for?
Presence and degree of dehydration
72
What are the red flags of gastroenteritis that indicate dehydration?
- Unwell or deteriorating
- Altered responsiveness
- Sunken eyes
- Tachycardia
- Tachypnoea
- Reduced skin turgor
73
What are the differentials for acute diarrhoea?
```
Gastroenteritis
Other infection
Constipation with overflow
Acute appendicitis
Intussusception
Coeliacs
DKA
Pyloric stenosis
```
74
When does gastroenteritis need investigating for a cause?
If it is part of an outbreak or there is:
- Sepsis
- Blood or mucus in stool
- Immunocompromise
- Recent foreign travel
75
How can gastroenteritis be investigated?
Bloods - FBC, U+Es
Blood culture
Stool sample for M,C+S
76
How should simple cases of gastroenteritis managed?
- Safety-net for red flags
- Encourage fluid intake - water or milk are best
- Continue breast feeding in infants
- Do not give solid foods
77
How should complicated cases of gastroenteritis be managed?
- ABCDE as appropriate
- Mx of dehydration
- Abx as appropriate
- Sepsis pathway as appropriate
78
What simple measures can be taken to prevent the spread of infective gastroenteritis?
- Wash hands with warm water and soap, and dry carefully.
- Do this after going to toilet, changing nappies, preparing, serving or eating food.
- Don’t share towels
- Stay home from school until 48 hours after last episode
- Wait 2 weeks before swimming in public pool
79
Which children are at highest risk of dehydration due to gastroenteritis?
- Those under a year old
- Low birth weight infants
- 5+ watery stools or 2+ episodes of vomiting in last 24 hours
- Infants who stop breast feeding or children who have had little fluid supplementary fluids
80
Other than dehydration, what complications can occur due to gastroenteritis?
Haemolytic uraemic syndrome
| Lactose intolerance following gastroenteritis (lactase flushed out)
81
How long does D+V usually continue?
5-7 days, but can last as long as 2 weeks.
82
What are the main ways in which we can prevent gastroenteritis?
- Breast-feeding
| - Rotavirus vaccine
83
How is rotavirus vaccine administered?
Oral dose at 2 months and 3 months
84
What general mechanisms can cause dehydration?
Decreased intake
Increased output
Shift of fluid (ascites/oedema)
Capillary leak
85
Are adults or children more susceptible to dehydration?
Children
86
What is the first step in managing dehydration in children?
Assess the degree of dehydration so the rehydration is appropriate.
87
What are most symptoms of dehydration related to?
Intravascular volume depletion
88
What kinds of dehydration can occur (in terms of electrolytes)?
Isonatraemic (most often)
Hyponatraemic
Hypernatraemic
89
What are the GI causes of dehydration in children?
- Gastroenteritis
- GI obstruction
- Bowel ischaemia
90
What are the oropharyngeal causes of dehydration?
- Mouth ulcers
- Stomatitis
- Pharyngitis
- Tonsillitis
91
What are the endocrine causes of dehydration in children?
- DKA
- Diabetes insipidus
- Thyrotoxicosis
- Congenital adrenal hyperplasia
92
What are some other causes of dehydration in children?
- Febrile illness
- Burns
- Heat stroke
- CF
93
Is it easy to assess degree of hydration in children?
Nope, but there are tools to help
94
What are the main signs that a child may exhibit if they are 5% dehydrated or more?
- Abnormal cap refill time
- Abnormal skin turgor
- Abnormal respiratory pattern
95
What degree of weight loss indicates mild dehydration?
1-5% weight loss
96
What degree of weight loss indicates moderate dehydration?
6-10% loss of body weight
97
What degree of weight loss indicates severe dehydration?
Over 10% loss of body weight
98
What are the clinical features of mild/moderate dehydration?
- Restless/irritability
- Sunken eyes
- Thirsty, drinks eagerly
99
What are the clinical features of severe dehydration?
- Abnormally sleepy or lethargic
- Sunken eyes
- Drinking poorly or not at all
100
How can the pinch test be used to assess dehydration?
Pinch skin, and see how long the skin fold is visible for.
Immediate recovery - normal hydration.
2s for skin to recover - mild/moderate dehydration
Very slow, over 2 seconds for skin to recover - severe.
101
What are the red flags of dehydration?
- Appears unwell or deteriorating
- Altered LoC
- Sunken eyes
- Tachycardia
- Tachypnoea
- Reduced skin turgor
102
A child presents with dehydration. He is constantly drinking water and urinates large volumes. What is your top differential?
Diabetes insipidus
103
How should ?diabetes insipidus be investigated?
```
Urine specific gravity
U+Es
24 hour urine collection for volume
Fluid deprivation test with response to desmopressin
MRI head
```
104
How should dehydration in a child be investigated?
Depends on the cause:
- Urine tests for specific gravity, ketones, and glucose
- Bloods - U+Es, bicarb, glucose, creatinine
- ECG - electrolyte disturbance may cause arrythmia
105
When are IV fluids indicated for a dehydrated child?
If there is severe dehyration/shock or oral fluids cannot be tolerated.
106
What oral rehydration solutions can be used for a dehydrated child?
Dioralyte
If breastfeeding, continue to give breast milk
107
A child needs IV fluids for rehydration, but is shut down peripherally. What is the quickest as safest way to gain access?
Intraosseous route for intraosseous infusion
108
Where is the preferred site for establishing intraosseous access?
Proximal tibia, below level of tuberosity.
109
What fluid bolus should be given to a child in shock?
20ml/kg of 0.9% sodium chloride over 15-30 minutes.
110
How many fluid boluses can be given to a child beofre an intensivist needs to be brought in?
2 x 20ml/kg boluses
111
What is the formula for calculating fluids needed to replace a deficit?
weight in kg x % dehydration x 10.
e.g. 14 kg child with 5% dehydration = 700ml
112
Other than fluids already lost and maintenance fluids, what other losses should be considered in dehydration?
Ongoing losses e.g. from NG tubes, drains, urine, increased insensible losses due to pyrexia or tachypnoea
113
How is fluid maintenance requirments calculated in a child?
100ml/kg for 1st 10kg + 50ml/kg or 2nd 10kg + 20ml/kg for any weight over 20kg.
114
How is monitoring of rehydration done in children?
Well-being of child
Observations
U&Es
Urine output
115
What is the normal urine output for an infant up to 1 year?
about 2ml/kg/hour
116
What is the normal urine output for a toddler?
1.5ml/kg/hour
117
What is the normal urine output for an older child?
1ml/kg/hour
118
A child comes in dehydrated and hypertonic, with a Na of 148. What do we need to do differently?
Replace the fluids slowly i.e. over 48 hours instead of 24.
| I.e. Maintenance fluids can carryo on as normal but replacement fluids should go up at half speed.
119
How quickly can hypertonic dehydration be corrected?
Na should not reduce any faster than 0.5 mmol/L per hour
120
What is coeliac disease?
Immune-mediated systemic inflammatory disorder caused by gluten, causing malabsorption of nutrients
121
What is gluten found in?
Wheat
Rye
Barley
122
Does coeliac disease have a genetic link?
Yes, more likely to have it if you have a positive FHx
123
How does coeliac disease present in children?
- Failure to thrive/faltering growth
- Persistent unexplained GI symptoms
- Severe mout ulcers
- Alingside other autoimmune conditions
- Alongside Turner's syndrome
- Alongside Down's syndrome
124
How should ?coeliac disease be investigated in children?
Total IgA and IgA tTg is the first choice.
FBC and iron studies as well as LFTs can confirm deficiencies secondary to coeliacs.
125
How is coeliac disease managed?
Lifelong strict gluten-free diet - need dietician input for substitutes and further support
126
Which nutrients are likely to be deficient in coeliac patients?
Vitamin D and iron
127
When do children with coeliac disease tend to present?
Following introduction of cereal into the diet, around 3 years of age
128
How is coeliac disease definitively diagnosed?
Jejunal biopsy showing subtotal villous atrophy
129
Why should coeliac patients be offered the pneumococcal vaccine every 5 years?
Due to a degree of functional hyposplenism which makes them more susceptible to it.
130
What is recurrent abdominal pain in children?
Recurring abdominal pain with no organic cause.
It usually occurs 4+ times a month over 2+ months.
131
Is recurrent abdominal pain in children common?
Yes - 10-20% of school-aged children experience it.
132
What is the most common form of recurrent abdominal pain?
Paediatric IBS
133
What is the pathophysiology of paediatric recurrent abdominal pain?
"A dysregulation of visceral nerve pathways, leading to visceral hyperalgesia. Infective, inflammatory or psychological triggers may initiate this sensitisation"
-Patient.info
134
If a child has recurrent abdominal pain, what other ymptoms might thye present with?
- Headache
- Joint pain
- Anorexia
- V+N
- Excessive gas
- Altered bowel habit
- Anxiety
135
Other than paediatric IBS, how can recurrent abdominal pain be classified?
- Functional dyspepsia
- Abdominal migraine
- Functional abdominal pain
136
What should prompt investiagtion for an organic cause in recurrent abdominal pain?
- Weight loss
- Faltering growth
- GI blood loss
- Significant vomiting
- Unexplained fever
- FHx of IBD
- Rashes
- Delayed puberty
- Oral or perianal lesions
137
How shoud recurrent abdominal pain with no organic cause be managed?
GP can manage in primary care - positive approach but explain no serious underlying pathology.
Clear explanation and active plan for management is good tool for reassuring both parent and child.
-Reduce/remove rewards for things that reinforce symptoms
-Encourage to maintain all normal activities
Progress is often rapid once normal routine is re-established
-Avoid over-investigation
Diet advice and exercise often beneficial
138
What is mesenteric adenitis?
Inflamed lymph nodes in the mesentery causing abdominal pain
139
What causes mesenteric adenitis?
It follows a recent viral infection
140
Where does the pain in mesenteric adenitis occur?
Central abdomen or RIF
This is an issue because it can be confused with appendicitis.
141
Does mesenteric adenitis need any treatment?
No - simple analesia can be given if required.
