GI/ Liver Flashcards
(51 cards)
1
Q
How many children are affected by constipation?
A
5-30% children. About a third develop chronic symptoms. Peak incidence is around 2-3 years (toilet training age)
2
Q
How is constipation characterised in children?
A
Infrequent bowel evacuations
Large stools
Difficult or painful evacuation.
3
Q
What is a normal stool frequency in the first week of life?
A
4 x a day
4
Q
What is a normal stool frequency at 1 year of age?
A
2 x a day. Breastfed infants tend to be less regular
5
Q
When is the normal adult range of passing stools attained in childhood?
A
The normal adult range (between 3 stools per day and 3 stools per week) is usually attained by 4 years of age.
6
Q
How do you define chronic constipation?
A
Two or more of the following for 8 weeks:
- Fewer than 3 bowel movements/ week
- More than one episode of faecal incontinence/week
- Stool palpable in the abdomen or rectally
- Passing stools so large they block the toilet
- Retentive posturing and withholding behaviours
- Painful defecation
7
Q
What is incontinence resulting from disease called?
A
Organic faecal incontinence
8
Q
What is incontinence not caused by organic disease called?
A
Functional faecal incontinence (90-95% of cases). Can be either:
- Constipation associated faecal incontinence
- Non retentive faecal incontinence (passage of stools in inappropriate places in children over the age of 4 with no organic disease/ constipation/ identifiable cause.
9
Q
What is faecal impaction?
A
Large faecal mass (felt in abdo/ rectum) that is unlikely to be passed on demand.
10
Q
What should a constipation history include?:
A
In addition to general history (past medical history, school and social history and family history, birth history)
-Parents can mistake incontinence for diarrhoea. In infants aged under 6 months, straining and crying for 10 minutes before passage of stools is caused by dyschezia (painful or difficult defecation which resolves spontaneously) and may be mistaken for constipation.
Specific questions should cover: The frequency of defecation. Consistency of stools - this may include use of the Bristol Stool Chart Episodes of faecal incontinence. Pain on defecation. Whether stools block the toilet. Any associated behaviour. Any pain on defecation is likely to lead to withholding.
Check for features in the history which are suggestive of idiopathic constipation, including:
- Meconium passed within 48 hours of birth (in a full-term baby).
- Onset of constipation at least a few weeks after birth.
- Presence of precipitating factors e.g.Dietary factors (for example changes to infant formula or weaning, poor diet, or insufficient fluid intake), Acute illness, such as infection, Anal fissure, Use of drug treatments such as sedating antihistamines or opiates, Timing of potty or toilet training, Psychosocial factors such as difficulty accessing a toilet, moving house, starting nursery or school, other major change in family circumstances, and fears and phobias.
11
Q
Specific examination in constipation should include:
A
- Palpation of the abdomen for faecal mass.
- Inspection for anal stenosis or ectopia.
- Looking for sacral abnormalities.
NB:
Rectal examination is not routinely necessary or required.
12
Q
Name some organic causes of constipation:
A
- Anorectal malformations e.g. atresia, anus not in right place
- Cow’s milk allergy
- Hirschprungs (presents very early)
- Spinal cord problems
- Metabolic/systemic e.g. CF, hypothyroidism, coeliac, hypercalcaemia
- Neuroenteric problems- e.g. decreased gastric mobility
- Pelvic floor dysynergia- inability to relax pelvic floor when attempting to defecate
13
Q
Functional causes of constipation:
A
Contributing factors for constipation include pain, fever, inadequate fluid intake, reduced dietary fibre intake, toilet training issues, the effects of drugs such as sedating antihistamines or opiates, psychosocial issues, and a family history of constipation.
Constipation is more common in children who are physically inactive or with impaired mobility (for example children with cerebral palsy) or a neurodevelopmental disorder (such as Down’s syndrome or autistic spectrum disorder).
14
Q
Complications of idiopathic constipation:
A
- Anal fissure, which may exacerbate a vicious cycle of pain leading to stool withholding, hard stool, and ongoing constipation.
- Haemorrhoids.
- Rectal prolapse.
- Megarectum- impaired sensation and soiling
- Faecal impaction and soiling.
- Volvulus.
- Distress for the child and family, physical discomfort, missed school, poor school performance, social isolation, and reduced involvement in group activities.
15
Q
Symptoms associated with defecation in a child older than 1 year of age:
A
- Poor appetite that improves with passage of large stool.
- Waxing and waning of abdominal pain with passage of -stool.
- Evidence of ‘retentive posturing’ — typical posture is straight-legged, on tiptoes with an arched back.
- Anal pain.
16
Q
Symptoms associated with defecation in children of any age:
A
- Distress or pain on passing stool.
- Bleeding associated with hard stool.
- Straining.
17
Q
Red and amber flags in constipation:
A
- Symptoms of constipation appearing from birth or during the first few weeks of life — may indicate Hirschsprung’s disease (congenital aganglionic megacolon).
- Delay in passing meconium for more than 48 hours after birth, in a full-term baby — may indicate Hirschsprung’s disease or cystic fibrosis.
- Abdominal distention with vomiting — may indicate Hirschsprung’s disease or intestinal obstruction.
- Family history of Hirschsprung’s disease.
- Ribbon stool pattern — may indicate anal stenosis (more likely to present in a child younger than 1 year of age).
- Leg weakness or motor delay — may indicate a neurological or spinal cord abnormality.
- Examination may reveal unexplained lower limb deformity or abnormal neuromuscular signs, including abnormal reflexes.
- Abnormal appearance of the anus (including fistulae; bruising; fissures; tight or patulous [widely patent] anus; anteriorly placed anus; or an absent anal wink [a reflex contraction of the external anal sphincter when the skin around the anus is stroked, may indicate spinal or neurological pathology]).
- Abnormalities in the lumbosacral and gluteal regions (such as asymmetry of the gluteal muscles, evidence of sacral agenesis, scoliosis, discoloured skin, naevi, hairy patch, sinus or central pit).
Amber flags also require specialist referral for assessment, but children with these signs may be treated for constipation in primary care whilst awaiting specialist assessment. They include:
Evidence of faltering growth, developmental delay, or concerns about wellbeing, which may indicate a systemic condition — liaise with a specialist to arrange testing for possible coeliac disease, hypothyroidism, cystic fibrosis, and electrolyte disturbance, if appropriate.
Constipation triggered by the introduction of cows’ milk
Concern of possible child maltreatment
18
Q
Management of constipation in red flags:
A
Do not treat, refer for urgent paediatric review
19
Q
Management of constipation with amber flags:
A
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.
20
Q
Management of idiopathic/functional constipation:
A
- Inform the child, parent and carers of diagnosis and there is no worrying features. Reassure and advise that treatment can take months.
- Assess for faecal impaction- overflow incontinence. If present, follow protocol.
- Give diet and lifestyle advice (fibre, fluids, exercise).
- Liaise with the school nurse.
- Refer if there is no response within three months.
21
Q
What dietary and lifestyle changes can be recommended for children with constipation?
A
- Foods with a high fibre content include fruit, vegetables, high-fibre bread, baked beans, and wholegrain breakfast cereals.Do not recommend unprocessed bran (which may cause bloating and flatulence and reduces the absorption of micronutrients) or fibre supplements.
- Do not switch formula feed or start a cows’ milk exclusion diet unless advised by specialist services.
-Advise normal daily physical activity that is tailored to the child or young person’s stage of development and ability
Approximately three-quarters of the daily fluid requirement in children is obtained from water in drinks. Higher intakes of total water will be required for children who are physically active, exposed to hot environments, or obese.
The following is a guide to adequate total water intake per day, including water contained in food. It should not be interpreted as a specific requirement:
Infants 0–6 months of age: 700 mL, assumed to be from milk.
Babies 7–12 months of age: 800 mL from milk and complementary foods and beverages, of which 600 mL is assumed to be water from drinks.
Children 1–3 years of age: 1300 mL (900 mL from drinks).
Children 4–8 years of age: 1700 mL (1200 mL from drinks).
Children 9–13 years of age:
Boys — 2400 mL (1800 mL from drinks).
Girls — 2100 mL (1600 mL from drinks).
Young people 14–18 years of age:
Boys — 3300 mL (2600 mL from drinks).
Girls — 2300 mL (1800 mL from drinks).
22
Q
What dietary and lifestyle changes can be recommended for children with constipation?
A
- Foods with a high fibre content include fruit, vegetables, high-fibre bread, baked beans, and wholegrain breakfast cereals.Do not recommend unprocessed bran (which may cause bloating and flatulence and reduces the absorption of micronutrients) or fibre supplements.
- Do not switch formula feed or start a cows’ milk exclusion diet unless advised by specialist services.
- Advise normal daily physical activity that is tailored to the child or young person’s stage of development and ability.
- Encourage increased water intake.
23
Q
What is the standard treatment for disimpaction of impacted faeces:
A
- Advise the child and/or their parents/carers that treating impaction can initially increase symptoms of soiling and abdominal pain, and ensure the child has easy access to a toilet.
- Offer the following oral laxative regimen, and review all children undergoing disimpaction within 1 week:
1. Prescribe a macrogol (Movicol®) first-line, using an escalating dose regimen. Ensure that an effective dose is used, and adjust the dose according to symptoms and response. It is unflavoured, but fruit squash may be added if preferred to improve adherence.
2. If this fails to lead to disimpaction after 2 weeks, add a stimulant laxative (such as Senna).
3. If the macrogol is not tolerated, substitute a stimulant laxative (such as senna) either on its own or, if stools are hard, in combination with lactulose or another stool softener laxative, such as docusate. - Consider seeking specialist advice or arranging urgent referral if all oral laxative regimens have failed. Do not routinely use suppositories or enemas in primary care.
- Start maintenance laxative treatment as soon as the bowel is disimpacted.
24
Q
What is the maintenance treatment for constipation?
A
- When there is no impaction or impaction has been treated.
- Prescribe a macrogol (movicol) first-line, using an escalating dose regimen. Ensure that an effective dose is used, and adjust the dose according to response to treatment. If the child required disimpaction, the usual maintenance dose is half the disimpaction dose.
- If constipation persists despite optimal doses of the macrogol, add a stimulant laxative (such as Senna). If diarrhoea occurs, reduce the dose of laxative(s) as prolonged diarrhoea can cause electrolyte disturbances, including hypokalaemia.
- If the macrogol is not tolerated, substitute a stimulant laxative (such as senna) and, if stools are hard, consider combining with lactulose or another stool softener laxative, such as docusate.
- Continue the effective dose of laxative(s) for at least several weeks after regular bowel movements are established, aiming for a soft regular formed stool. This may take several months to achieve- some say at least 2x as long as constipation has been occurring.
- Consider seeking specialist advice or arranging referral if all oral laxative treatments have failed. Do not routinely use suppositories or enemas in primary care for maintenance treatment.
- Arrange regular follow-up, the frequency depending on clinical judgement, to advise about gradually reducing and stopping laxatives over months.
- Children that are toilet training should remain on laxatives until this is well established.
25
Definition of GOR:
Gastro-oesophageal reflux (GOR) is the passage of gastric contents into the oesophagus. It is considered physiological in infants when symptoms are absent or not troublesome.
26
Definition of GORD:
Gastro-oesophageal reflux disease (GORD) in children is the presence of troublesome symptoms (for example, discomfort or pain) or complications (such as oesophagitis or pulmonary aspiration) arising from GOR.
27
Definition of regurgitation:
Regurgitation (also known as 'posseting') is the voluntary and involuntary movement of part or all of the stomach contents up the oesophagus at least as far as the mouth and often emerging from the mouth.
In children it may be a symptom of GOR or GORD.
In infants (younger than 1 year of age), regurgitation may be considered entirely normal.
28
Causes of GOR:
Transient relaxation of the Lower Oesophageal Sphincter
29
Why is GOR more common in children?
- Shorter, narrower oesophagus
- delayed gastric emptying
- Shorter, lower sphincter that is slightly above the diaphragm
- Liquid diet and high calorific requirement putting a strain on gastric capacity.
- Larger ratio of gastric volume to oesophageal volume.
30
How common are regurgitation of feeds?
- 40% of infants
| - Number of affected by GORD is much much smaller
31
Risk factors for GORD:
- Premature birth.
- Parental history of heartburn or acid regurgitation.
- Obesity.
- Hiatus hernia.
- History of congenital diaphragmatic hernia (repaired).
- History of congenital oesophageal atresia (repaired).
- Neurodisability (such as cerebral palsy).
32
Complications of GORD:
Many do not get complications but the following are possible:
- Reflux oesophagitis.
- Recurrent aspiration pneumonia.
- Recurrent acute otitis media (more than three episodes in 6 months).
- Dental erosion in a child with neurodisability (for example cerebral palsy).
Rare complications include:
- Apnoea
- Apparent life-threatening events (episodes of combinations of apnoea, colour change, change in muscle tone, choking, and gagging that are sometimes considered 'missed' sudden infant death syndrome).
33
What is the prognosis of GORD and regurgitation:
Regurgitation and gastro-oesophageal reflux disease (GORD) usually begin before the age of 8 weeks and resolve in 90% of infants (90%) before 1 year of age
Improvement in regurgitation and GORD is thought to occur because of:
An increase in length of the oesophagus.
An increase in tone of the lower oesophageal sphincter.
A more upright posture.
A more solid diet.
34
How to diagnose GORD?
Suspect GORD in any infant (up to 1 year of age) or child if they present with regurgitation and one or more of the following:
- Distressed behaviour shown, for example, by excessive crying, crying while feeding, and adopting unusual neck postures).
- Hoarseness and/or chronic cough.
- A single episode of pneumonia.
- Unexplained feeding difficulties (for example refusing to feed, gagging, or choking).
- Faltering growth.
Children over 1 year of age may present with heartburn, retrosternal pain, and epigastric pain.
35
Red flag symptoms when suspecting GORD?
- Projectile vomiting
- Yellow/green vomit
- Abdo distension, tenderness or mass
- Haematemesis
- Bulging fontanelle or increasing head size with early morning vomiting- raised ICP
- Diarrhoea/ high risk of atopy- cow's milk allergy
- Onset of regurgitation after 6 months of age and persisting after 1 year- presentation of UTI?
- Fever/ unwell child
- Malaena
- Dysphagia
36
When to refer a child with reflux?
- Admit on same day if malaena, dysphagia or haematemsis
| - Refer to paeds if red flag symptoms or unexplained iron deficiency anaemia, growth delay, reluctance to feed etc.
37
How to manage simple regurgitation in children?
For infants and children who have regurgitation, offer reassurance and advise parents and carers that in well infants, effortless regurgitation of feeds:
-Is very common (it affects at least 40% of infants).
-Usually begins before the infant is 8 weeks old.
-May be frequent
-Usually becomes less frequent with time (it resolves in 90% of affected infants before they are 1 year of age).
Treatment or further investigation is not normally required.
-Come back for review if projectile vomiting, billows vomiting, marked distress, growth delay or other new concerns.
38
How to manage GORD first line in formula fed infants with frequent regurgitation and marked distress?
-Refer early if complications or worrying features
Consider a stepped care approach:
- Reduce the volume of feeds (only if this is excessive), then a total feed volume of 150 ml/kg body weight over 24 hours (6–8 times a day) is usually recommended.
- Offer a 1–2 week trial of smaller, more frequent feeds (ensuring that the total daily volume of feeds remains the same), then
- Offer a 1–2 week trial of feed thickeners such as a pre-thickened formula (for example Enfamil AR® and SMA Staydown®) or a thickener that can be added to the usual infant formula (for example Instant Carobel®). Enfamil AR® and SMA Staydown® are both indicated for a maximum of 6 months — a normal teat can be used. Instant Carobel® — a teat with a larger hole or a variable flow (split) will be required.
- If this stepped care approach is not successful, consider stopping the thickened formula, and offering a 1–2 week trial of alginate therapy (Gaviscon® Infant) added to formula.
If symptoms improve after a 1–2 week trial of alginate therapy (Gaviscon® Infant) continue with this therapy.
Advise the parents or carers to stop treatment at regular intervals (for example every 2 weeks) in order to see if symptoms have improved and if it is possible to stop treatment completely.
39
How to manage GORD first line in breastfed infants with frequent regurgitation and marked distress?
-Refer early if complications or worrying features
If symptoms persist, consider prescribing a 1–2 week trial of alginate therapy (for example Gaviscon® Infant) mixed with water and given after each feed.
If symptoms improve after a 1–2 week trial of alginate therapy (Gaviscon® Infant) continue with this therapy.
Advise the parents or carers to stop treatment at regular intervals (for example every 2 weeks) in order to see if symptoms have improved and if it is possible to stop treatment completely.
40
How to manage GORD in both breast fed and formula fed infants when the first attempts have not worked:
If symptoms remain troublesome despite a 1–2 week trial of alginate therapy, consider prescribing a 4-week trial of a histamine-2 receptor antagonist (such as oral ranitidine). You can also try a proton pump inhibitor (such as oral omeprazole) but this must be specially made by the pharmacy.
If symptoms still persist despite the above interventions, consider referral to a paediatrician or paediatric gastroenterologist (the urgency of referral depending on clinical severity) for assessment and specialist management..
41
How to manage GORD in children age 1-2 years.
Consider a 4-week trial of a proton pump inhibitor (such as oral omeprazole) or a histamine-2 receptor antagonist (such as oral ranitidine).
If symptoms do not resolve or recur after stopping treatment, consider referral to a paediatrician or paediatric gastroenterologist. The urgency of referral depends on clinical judgement.
42
Ranitidine counselling:
Adverse effects of ranitidine are uncommon and include diarrhoea, headache, dizziness, rash, and tiredness
43
Gaviscon counselling
Prescribed as doses (half of a dual sachet).
Do not use with feed thickeners e.g. carobel, SMA stay down, enfamil.
Can lead to gastric distension .
44
Omeprazole counselling
Oral suspension is unlicensed in infants
Adverse effects of omeprazole are usually mild and reversible and include headache, diarrhoea, nausea, abdominal pain, constipation, dizziness, and skin rashes
45
More serious investigations into GORD:
Oesophageal pH study- if suspecting LRD instead
Upper GI contrast study if you suspect intestinal obstruction due to bile-stained vomit
Endoscopy if oesophagitis is suspected
46
What is laryngopharyngeal reflux disease (LRD):
- LRD is defined by the reflux into the larynx, oropharynx, and/or nasopharynx.
- LRD is believed to contribute to a variety of conditions, including failure to thrive, laryngomalacia, recurrent respiratory papillomatosis, chronic cough, hoarseness, -oesophagitis, and aspiration.
- Diagnosis is based on a high index of suspicion if there are no symptoms specifically indicating GOR, and with confirmation by investigation, including endoscopy, pH probes, and radiographic studies.
Management is the same
47
Surgical options in GORD:
Consider fundoplication in infants, children and young people with severe, intractable GORD if appropriate medical treatment has been unsuccessful or feeding regimens to manage GORD prove impractical - eg, for long-term, continuous, thickened enteral tube feeding.
48
What is mesenteric adenitis?
It is due to non- specific inflammation of the mesenteric lymph nodes which provokes a mild peritoneal reaction and stimulates painful peristalsis in the terminal ileum.
49
Aetiology of mesenteric adenitis
Mesenteric lymphadenitis usually follow viral infection with the common cold, or with infection by Yersinia enterocolitica, Pseudo tuberculosis, Streptococcus viridansor Campylobacter jejuni.
The small intestine is frequently more involved, but the large intestines or colon may also be involved.
The lymph nodes become enlarged due to inflammatory process induced by the micro-organisms.The inflammatory process, coupled with the stretch effect on the wall of the mesentery by the enlarged lymph node cause pain.
Pus may form in severe cases and spread to cause disseminated infection.
Most times though, the infection resolves on it own without the need to do anything.
50
Symptoms of mesenteric adenitis and how is this different to appendicitis?:
-Non-specific abdominal pain which resolves in 24–48 hours. The pain is less severe than in appendicitis, and tenderness in the right iliac fossa is variable. It is a colicky abdominal pain which just resolves momentarily without any intervention. The sufferer may be completely pain free between attacks. Characteristically, the pain moves from one spot to the other on the abdomen, in keeping with the movement of the bowel loops in the abdominal cavity.
Asking the child to turn to the left side will demonstrate this shift as the area of pain and tenderness will move along with the bowel to the left.
- Preceding Cold or Sore Throat in the days or week before the onset of abdominal pain. There may even still be an on going cough and cold in the child. The neck glands, if examined may still be swollen.
- Fever. There may be an associated fever, running up to 38.5 degrees centigrade.
- Patient may vomit. If they vomited before the onset of pain, appendicitis is most unlikely.
- Diarrhoea. There may be episodes of loose stools, especially where Yersinia infection is involved. Appendicitis could also cause diarrhoea.
- Anorexia. Usually, with mesenteric lymphadenitis, patients are still able to eat and drink. If a patient complains of abdominal pain, and appetite remains good, it is most unlikely he or she has appendicitis.
51
How to diagnose mesenteric adenitis:
Diagnosis of mesenteric lymphadenitis is most commonly from the history and examination.
PT- in young adult women
Full blood Count. This may show evidence of infection, with elevated white blood cells. It can not differentiate between appendicitis, mesenteric lymphadenitis, or any other infection.
Yersinia enterocolitica Serology. A positive serology will support the diagnosis of mesenteric adenitis.
Ultrasound Scan. This may demonstrate hypoechoic nodules, which will be quite different from the surrounding tissues. Mesenteric thickening will also support a diagnosis of mesenteritis.
CT Scan. If done because the cause of abdominal pain remains unclear, in mesenteric adenitis, contrast CT will demonstrate enlarged mesenteric lymph nodes, plus a normal appendix.
Laparoscopy. If the diagnosis is still in doubt, a laparoscopy may lay it to rest. At laparoscopy, the lymph nodes surrounding the terminal ileum and colon may be found to be more in number and enlarged, with swelling of the mesentery, and a normal looking appendix.
Most commonly, pure observation in hospital is used to distinguish appendicitis from mesenteric adenitis.
